Eating disorder in-patient admissions: Children and young people (Paediatric Guidelines)

• Management of physical complications of severe malnutrition, and/or associated behaviours e.g. electrolyte disturbance, marked hypothermia, severe bradycardia, cardiac arrhythmia, dehydration (medical instability).
• Re-feeding for severe malnutrition whilst awaiting a bed in CAMHS Inpatient Unit (for age 13 and over)  or Dudhope Young People’s Unit or Skye House (for ages 12 and under).
• Begin process of re-feeding; to be continued at home once stabilised.
• Management of an acute medical illness unrelated to but complicated by an eating disorder.

The ward should NOT be used to manage a young person with an eating disorder as an alternative to a mental health unit. However, occasionally if there is a delay in finding an appropriate mental health placement, the patient may have to remain on the ward due to the risk of deterioration should they return home. 

Anorexia nervosa (AN)

A serious medical condition characterised by restricted oral intake, resulting in low body weight and a significantly compromised physical state. It has one of the highest mortality rates of all Psychiatric conditions; the patient often has limited insight into their illness, due to the physical effects of severe malnutrition. It is accompanied with distorted beliefs around body image; weight and shape concerns; and an intense fear of gaining weight (patients may present with body dysmorphia). Alongside restricted oral intake, purging behaviours may be present e.g. excessive exercise, self-induced vomiting, diet pills and laxative/diuretic abuse.

Young people with AN may not have a low age-adjusted BMI. If they have previously been overweight/ obese and are losing weight rapidly (progressive weight loss of 1 kilo or more per week, or 10% or more of overall body weight), they may be medically compromised despite being a “healthy” BMI/ weight for height.

Avoidant restrictive food intake disorder (ARFID)

A condition characterised by the person avoiding certain foods or types of food, having restricted intake in terms of overall amount eaten, or both. Unlike AN there are no concerns with body image or weight. ARFID can result in significant concerns with weight loss, nutritional deficiencies, psycho-social functioning. ARFID is usually due to the following reasons:

• Sensory Sensitivities: the individual might be very sensitive to the taste, texture, smell, or appearance of certain types of food, or only able to eat foods at a certain temperature. This can lead to sensory-based avoidance or restriction of intake. ARFID often co-occurs with Autism Spectrum Condition (ASC).
• Fear of aversive consequences: this could be due to traumatic experiences with food, such as choking, vomiting, or experiencing pain when eating, or specific anxieties or obsessional thoughts. This can cause the person to develop feelings of fear and anxiety around food or eating, and lead to them to avoiding certain foods and/or fluids.
• Lack of interest: in some cases, the person may not recognise that they are hungry in the way that others would; view eating as a chore; or they may generally have a poor appetite, resulting in them struggling to eat enough. When this is paired with low mood eating becomes even harder.

Patients with longstanding ARFID may be at higher risk of re-feeding syndrome due to poor baseline nutrition. If a patient has longstanding malnutrition due to ARFID they may be more physiologically stable than a patient who has lost weight quickly. This should always be confirmed with monitoring of observations, bloods and not be assumed. Multivitamins should be prescribed, and patients managed by dieticians, medical professionals and CAMHS practitioners.

If patients with ARFID are undergoing re-feeding, their need for accepted foods should be accommodated and reasonable adjustments made to meal plans. These accommodations will be clearly communicated in the ward care plan as children with selective eating need flexible plans that are informed by the best assessment and formulation of their selective eating. Please see the section on the PEACE pathway later in this document.

Bulimia nervosa (BN)

Characterised by a pattern of eating large quantities of food (bingeing), and then compensating for the overeating (purging), typically in the form of self-induced vomiting; laxative or diuretic misuse; restricting oral intake; or excessive exercise. This is accompanied with a sense of loss of control over their eating, as well as distorted beliefs around body image; weight and shape concerns; and a fear of gaining weight.

Whilst a patient may have a ‘healthy’ body weight with BN; there are several serious physical risks associated with purging behaviours e.g. electrolyte imbalance, which may result in them becoming medically compromised requiring stabilisation.

Other specified feeding or eating disorder (OSFED)

Anorexia, bulimia, and binge eating disorder are diagnosed with specific behavioural, psychological, and physical criteria and symptoms. Sometimes a person’s symptoms do not fit these typical criteria and they may have a diagnosis of OSFED instead. This includes atypical anorexia and bulimia nervosa and binge eating disorder of low frequency/ limited duration.

Nutritional concerns within other psychiatric conditions

Some patients may have severe food (and sometimes fluid) restrictions that affects their physical and nutritional status, secondary to another psychiatric disorder e.g. depression, OCD or psychosis. Keeping the patient safe by working together as an MDT to ensure adequate intake, minimising re-feeding risk while addressing the underlying psychiatric condition is the required treatment.

Throughout any admission, the consistent, co-ordinated care and support of the young person and their family from a physical and psychological perspective is paramount. It is the responsibility across all teams and professionals to ensure that there is multidisciplinary collaboration, so that all aspects of management are addressed appropriately.

The specific medical and nutritional aspects of treatment whilst a young person is an in-patient fall within the remit of Paediatricians/ Medical Consultants alongside ward nursing staff, and Dietetics. The CAMHS team has responsibility for overseeing and advising on psychological aspects of the treatment plan.

Inpatient medical team

• Complete the MEED risk assessment. Patients with one or more Red rating or several Amber ratings should be considered high risk, with a low threshold for admission. However, use of clinical judgement is essential within this risk assessment.
• Completion of ward paper work e.g. ward MEED checklist.
• Ruling out any other differential diagnoses e.g. coeliac disease, diabetes, thyroid function, IBD.
• Safely re-feed the patient by avoiding re-feeding syndrome caused by too rapid re-feeding whilst avoiding underfeeding by being too cautious. Close monitoring of the patient and discussions with dietetics and nursing staff is essential during this process.
• Establishing physical health monitoring needs: e.g. ECG, blood sugar monitoring, telemetry, bed rest.
• Manage fluid and electrolyte problems.
• Arrange discharge, in agreement with CAMHS, as soon as possible once such treatment is safe and indicated.

Ward nursing staff

In hospital, the multidisciplinary team will be responsible medical stabilisation and nutritional rehabilitation. Nurses will usually be responsible for making sure the meal plan or feed is provided and administered and observing that it is not disposed of by the patient.

Patients with eating disorders often engage in behaviours which limit weight gain and falsify weight. Nurses are in a good position to identify these behaviours and intervene to manage them in a supportive and empathetic way. Nurses without experience of nursing young people with eating disorders should be supervised by more senior nurses. Clear documentation of any challenging behaviours and food/fluid intake are crucial.

• Meals: All meals need to be supervised by a health care professional/ family (where appropriate) and each item of food or fluid recorded.
• Observations: BP, heart rate, temperature and respiratory rate taken and recorded as frequently as advised by the medical team.
• Pressure area care: observe for signs of skin breakdown. Nurse on pressure mattress if indicated, to prevent pressure sores and a Waterlow score documented in the nursing notes.
• Patient height: This is to be recorded on admission. 
• Patient weight: This is to be recorded twice weekly (usually Mondays & Thursdays) and clearly documented and recorded. Weight to be recorded in underclothes, post void, before breakfast on first full day of admission.
• No exercise should be allowed initially until discussed with medical and CAMHS teams.
• Compensatory behaviours: Nursing staff should be aware of the compensatory behaviours of vomiting, excessive exercise or not sitting down. Please observe for such practices, especially after meals and snacks and document accordingly.

Dietetics (Acute & CAMHS)

Dietetics will advise on the re-introduction of nutrition and, alongside medical colleagues, closely monitor the risk of re-feeding syndrome and underfeeding. Dietetics can advise on the most appropriate route of refeeding e.g. orally with food, oral nutritional supplements, enteral feeding, or a combination of these, depending on physical and nutritional risk. The use of meal plans, and meal support is the preferred first line treatment in children and young people.

Acute Dietetics should be informed as quickly as possible by the Acute Medical Team when a young person is admitted with an eating disorder or suspected eating disorder, so that assessment and nutritional treatment can be promptly arranged.

• Patient admitted to the Highland Children's Unit: Contact paediatric dietetics (pager: 1068 or extension: 5097).
• Patient admitted to GA/ 7C: Contact adult gastroenterology dietetics (pager: 6065 or extension: 4325).

The CAMHS dietitian will usually be made aware of any admissions at the morning huddle, or if CAMHS have arranged the admission.

The lead dietitian for the case will be agreed between dietetics e.g. the CAMHS dietitian may see the patient on the ward if they are already well known to the CAMHS team. Acute dietetics will usually be involved in the initial stages of re-feeding. Acute and CAMHS dietetics should liaise closely regarding the patient’s progress and discharge planning.

On-going dietetic input as an out-patient should be agreed within the CAMHS team as not all patients will require regular dietetic in-put in the community.

If the patient is transferred to a Young Person Unit (YPU) for further treatment, then a prompt dietetic handover should be provided to the unit.

CAMHS Eating Disorder Team

CAMHS has responsibility for overseeing and advising on psychological aspects of the treatment plan by:

• Supporting development of a collaborative bio-psycho-social formulation that guides interventions to improve eating behaviour
• Monitoring of mental state
• Advising on consent and psychotropic medication
• Mental Health Act assessments
• Psychological risk assessment and management plan
• Liaising with in-patient mental health units/ young person units (YPU) regarding transfer of care when required.

If the patient is admitted as a first presentation and not known to CAMHS, the CAMHS Eating Disorder Team should aim to assess the patient on the ward within 2 working days.

Psychiatry

The Consultant Psychiatrist will be the lead CAMHS clinician during in-patient admissions and must always be part of the CAMHS initial ED assessment team. They will work in collaboration with the medical and ward staff to ensure treatment is appropriate and effective. Continual review and assessment around the need for compulsory treatment (under legal order) will be part of their role. The named psychiatrist for the patient should be contacted as soon as possible if there are any concerns regarding a patient's compliance with treatment and capacity. Depending on whether the young person is detained under the Mental Health Act, some treatments may or may not be possible. The medical and CAMHS team will discuss and agree which treatments will be used. Psychiatric consultation with patient, family/carers, mental health advocate and medical team is essential in this process.

Psychology

In the initial stage a psychologist may not be working directly with a child, but consult to the MDT around them, particularly about the impact of care plans for future recovery and wellbeing. They can provide an assessment (alongside medical intervention and stabilisation) in the first instance to aid development of a psychological formulation (understanding around the development and maintenance of the eating disorder/ difficulties and co-morbidities), to help inform care planning; this will include the views of the young person, parent(s)/ carer(s) and wider system.

The formulation will be used to determine the type of psychological interventions / models to be used in further treatment following medical stabilisation.  

CAMHS Nursing

The CAMHS nursing team will provide clinical support to assist in the implementation of multi-disciplinary agreed plans of care, intensive therapeutic contacts where required and will assist in developing and maintaining agreed risk assessment plans. CAMHS nursing input is in place to provide continuity and to advocate for young people and their families, so their voices are heard and considered at every stage of a child or young persons treatment journey.

MEED guidelines should be followed for all patients presenting with an eating disorder. Patients can look very well but may be minimising illness or unaware of how unwell they are. The risk assessment framework should be completed for all eating disorder assessments.

Risk assessment framework for assessing impending risk to life (<18 years)

Printable MEED Risk Assessment

Examinations

Patients should be examined paying particular attention to:

• Cardiovascular instability and complications:
  • cool peripheries, acrocyanosis, bradycardia, postural hypotension, mitral valve prolapse, arrhythmias, hypotension (use age-adjusted charts)
• Signs of electrolyte instability
• Pubertal development: 
  • growth assessment and documentation of pubertal stage.
• Signs of vomiting: 
  • gingivitis and dental caries, loss of enamel on teeth, callouses on dorsum of the hand (Russell’s sign), swollen parotid glands.
• Signs to suggest alternative diagnosis.
• Baseline 12 lead-ECG on admission to assess for prolonged QTc interval.
  • Haemodynamically unstable patients should be monitored with continuous cardiac monitoring.

Median percentage BMI (also called weight-for-height)

To complete a full MEED risk assessment in a patient <18 years old you will need to know their median % BMI (weight-for-height). To calculate this, please see the table below and equation.

Blood tests

All patients with a suspected eating disorder should have the following blood tests on admission:

• U&E’s
• Full blood count
• LFT’s
• Glucose­­
• Phosphate, magnesium, calcium
• Venous blood gas
• Thyroid function tests
• Coeliac screen
• Vitamin B12, ferritin and folate

Differential diagnosis

Differential diagnosis should be considered and ruled out e.g:

• hyperthyroidism, Addisons, inflammatory bowel disease, coeliac disease, malignancy.

Patients with significant malnutrition can also have a degree of immunocompromise and infections should be identified and treated promptly.

Nutrition screen

To be discussed with Dietetic team if required:

• Full nutrition screen, including fat soluble vitamins (A, D and E).

Patients with diabetes

Diabetic patients with eating disorders are particularly high risk and the diabetic team should be involved as soon as possible.

• See MEED guidelines: Annex 3 Type 1 diabetes and eating disorders (T1DE)

Re-feeding syndrome is a potentially fatal condition that can occur when food intake has been severely restricted. The sudden reversal of prolonged starvation by the reintroduction of nutrition, leads to rapid shifts of electrolytes back into cells from being leached out during starvation. The resulting effects, most notably cardiac compromise, can be fatal. Respiratory failure, liver dysfunction, central nervous system abnormalities, myopathy and rhabdomyolysis are also recognised complications and patients are at risk of vitamin deficiencies.

Refeeding syndrome can occur within 72 hours of re-introducing nutrition, with a range of 1 to 5 days, however there can be a delayed response in re-feeding (in one study, up to 18 days) in the most malnourished.

Indications someone may be high risk of re-feeding syndrome

• Rapid weight loss >1kg per week
• Minimal or no intake for > 4 days
• Severe malnutrition (<70% weight for height/ median BMI) or weight loss of over 15% in the past 3 months.
• Deranged baseline electrolytes
• Low WCC (<3.8)
• Medical co-morbidities e.g. infection or other serious disease

Underfeeding risks

While re-feeding syndrome is an essential consideration in patients with anorexia nervosa and other restrictive eating disorders, there have been more reported deaths in anorexia nervosa from underfeeding, which can occur because staff fear inducing refeeding syndrome. It is essential that nutrition is increased swiftly but safely to prevent underfeeding and re-feeding syndromes.

Vitamin and mineral supplementation

Any patient at high risk of re-feeding syndrome should be started on

• Thiamine 50 mg four times daily PLUS Forceval capsule or Forceval soluble once daily for the first 10 days of re-feeding until feeding is fully established OR until advised by dietitian.

Notes:

• Use Junior Forceval for 6 to 11 year olds
• Forceval capsules are contraindicated in peanut and soya allergies and those who are vegan or vegetarian (capsule contains gelatine).
• IV Vitamins B+C infusion once daily can be used instead of thiamine if thought to be indicated in extremely high re-feeding risk or if oral route / tablets via NG contraindicated.

Admissions of patients requiring treatment for an eating disorder should be planned so that all members of the multidisciplinary team are prepared prior to admission (CAMHS, ward Nursing staff, Medical staff, Dietetics etc). However, if the patient is admitted out of hours, follow out-of-hours guidance on TAM.

This checklist should be completed by the Medical Consultant in liaison with other members of the MDT, so that a clear plan for all members of staff, patients and families is made. This should continue to be reviewed on a daily basis.

Ward admission checklist

Nutritional treatment: oral, NG & NG feeding under restraint

The provision of nutrition and management of mealtimes on the ward are essential in treating and improving the young person’s physical health. It is important that all staff see the provision of nutrition as equally important to any prescribed treatment. The use of meal plans, and meal support is the preferred first line treatment in children and young people.

The dietitian will provide an appropriate re-feeding plan. Meal plans can be adapted for genuine food dislikes that preceded the eating disorder, confirmed by parents or family members.

Most young people under 18 years old can be safely commenced on a feeding plan of at least 1,400kcal per day, even if they are thought to be high risk of re-feeding syndrome. Patients should not be started on less than their reported intake prior to admission, however this can be difficult to assess accurately and gathering information from parents and carers is essential.

Energy intake should increase by at least 200kcal every 1 to 2 days (depending on re-feeding risk), up to 2,400kcal per day if needed. Clinical judgement should be used to minimise the risk of underfeeding.

Weight should also improve by > 0.5kg/ week. Electrolytes must be corrected as soon as possible, and re-feeding should not be delayed during this process. If there are significant concerns with electrolytes dropping, then nutritional intake should not be advanced until safe to do so.

Oral intake

Most patients should be commenced on Meal Plan 1 (1,400kcal) and can be increased by at least 200kcal every 2 days, until they can be fully assessed by a dietitian. See: Meal plans section.

Each meal plan will have an equivalent volume of suitable oral nutritional supplement that must be provided if the meal or snack is refused or if the full meal or snack has not been eaten. If there is continued refusal of food and oral nutritional supplement orally, then NG tube feeding will need to be discussed and considered by the multidisciplinary team and use of the mental health act may be required for this. 

A patient copy of the meal plan should be provided to the patient and family so that they are aware of what should be ordered at each meal and snack. The calorie content of the meal plan and the volume of the Fortisip should be removed from the patient copy to minimise distress. The patient should NOT have access to the staff copy of the meal plan. In some cases it may be agreed that ward nursing staff will order on the patient’s behalf and staff should order meals and snacks as per the meal plan. 

• ALL food and fluids must be documented clearly on food and fluid charts so that the dietitian can calculate the total amount that has been managed daily.
• ALL meals, including snacks, must be closely supervised.
• Meals should be limited to 30 minutes, snacks limited to 15 minutes and Fortisip top-ups limited to 10 minutes.

Staff should be aware that mealtimes may be very difficult and distressing for patients and they may require a great deal of support. See: Mealtime management section.

Naso-gastric tube (NGT) feeding

NGT feeding should be seen as a last resort to the dietary management of a young person with an eating disorder. However, if it is required due to the patient's medical needs, then the aim is to use it for the shortest time possible and to continue to encourage the young person to eat instead.

In cases that NG feeding is advised we recommend a multiagency meeting to review dietetic, medical and psychological possibilities to either avoid enteral feeding or to consider a multidisciplinary exit plan from enteral feeding when it is required.

Least restrictive practice is essential in the patients care and the patient should be offered the option to eat at every opportunity e.g. they have the option to eat the meal or snack as per the meal plan, the next option is to drink the equivalent Fortisip volume, the next option is to have the Fortisip volume bolused via the NGT by syringe NOT by gravity or pump.

Initiating NGT feeding should be based on a review of the young person’s progress and level of physical risk. Any decision to initiate NGT feeding should be made following consultation with the young person, their family and the MDT, with clear a clear exit plan developed. Ideally the MDT would include a dietitian, nursing staff, medical consultant, consultant psychiatrist and psychologist, unless their medical state requires more urgent intervention. If the child or young person consistently and actively resists treatment, consideration should be given to treating the young person under the Mental Health Act. The CAMHS Consultant Psychiatrist should be contacted as soon as possible for further assessment if the patient is not consenting to treatment.

Considerations when NG feeding

• Where possible, the patient should be taken to a quiet, calm area to have the NGT passed with as few people as possible present.
• The NGT should be passed and left in situ. There may be some indications where it is appropriate to remove and re-pass the NGT e.g. ligature risk or sensory issues, however this should be discussed on a case-by-case basis.
• Bolus feeding by syringe would be the recommended method unless otherwise indicated.
• Staff should continue to offer food as per meal plan and communicate a high expectation that the food will be eaten. If food or oral nutritional supplements are refused or no attempt is made to eat or complete the meal/ supplement in the time limits set, then a bolus feed is to be given via the NGT.
• If the young person does eat, they need to comply fully with the daily meal plan until the next review day, when a decision will be made as to whether the NGT can be removed. Patients should be given a positive message that the NGT will be removed if they comply fully with the prescribed daily meal plan.
• All due care for the NGT’s should be given: checking the position and state of tube and documenting this care.
• The use of bridles is not indicated in this patient cohort. However, this should also be reviewed on a case-by-case basis as some patients may prefer the use of bridles to minimise movement of the tube and to reduce tube displacement.
• If the young person continually pulls out the NGT and distress around feeding is too great to be managed through reassurance and talking, further discussion with the MDT, including the Medical Consultant and Duty Psychiatrist, must take place to decide the next course of action.

NG feeding under restraint

When a young person is at risk of death from malnutrition caused by an eating disorder, and is refusing any treatment, NGT feeding under restraint may be required as a lifesaving intervention. On these occasions, discussions and careful planning should take place with the MDT and responsible Consultant Psychiatrist as soon as possible. An exit strategy must be discussed before starting this procedure, and the need for NGT feeding under restraint should be reviewed daily.

To reduce distress, length and frequency of restraints required, practice should be adapted to using a larger volume of bolus feeds, by syringe, via the NGT, as few times as possible e.g. 1 to 2 times per day.

There are various levels of restraint, from one member of staff holding the patient's hands to several members of staff being required to hold the young person’s arms, legs and/or head. The level of restraint required should be negotiated with the patient prior to the intervention and agreed as a team carrying out the intervention.

Staff must be appropriately trained in this intervention. The Violence and Aggression Team should be consulted for advice and further training if required.

• The bolus feed plan should be provided by the dietitian. Each patient should have an individualised dietetic plan and meal plan in place, so that the patient is aware what they need to eat or drink, in order to avoid bolus feeding.
• Feeding under restraint should be done via syringe bolus, not gravity feeding or via enteral pump, as these would prolong the time of the restraint.
• The planning of the restraint should be agreed and discussed as a team, and with the patient.
• Food and/ or nutritional supplements should continue to be offered at every opportunity. It should not be assumed that the patient will not eat.
• Patient safety must be maintained and closely monitored throughout the procedure.
• The need for feeding under restraint must be reviewed by the MDT daily. If safe, then the frequency of boluses and restraint can further reduce depending on physical risk e.g. to every 2^nd or 3^rd day.

A staff debrief should be held after each episode of NG feeding under restraint as it is a distressing intervention for staff as well as the patient.

Post feed distraction and support should be provided to the patient, ideally by a member of the team not involved in the restraint procedure, or by a family member.

Further guidance and research regarding NG feeding under restraint in children and young people can be found below.

• NG feeding in restraint
• Dietitian NG under restraint - 2020 - Fuller
• Decision-making-and-best-practice-when-nasogastric-tube-feeding-under-restraint-multi-informant-qualitative-study.pdf
• The-importance-of-individualised-care-good-communication-and-trust-for-reducing-nasogastric-tube-feeding-under-physical-restraint-qualitative-multi-informant-study.pdf
• NG feeding algorithm

PEACE pathway and sensory issues

• PEACE Pathway - About PEACE

Some patients may have significant sensory challenges for example texture sensitivities in context of ARFID or Autism. The PEACE Pathway (Pathway for Eating Disorders and Autism Developed from Clinical Experience) is a network where clinicians, carers and patients have shared useful information and resources in supporting those with an eating disorder and autism.

For those struggling with a sensory restrictive eating disorder, either within the context of ARFID, autism and/ or sensory processing disorder, some reasonable adaptions can be made and discussed with the MDT. Examples are given below.

Consider options such as how the food can be presented with a routine appearance, how it can be made more acceptable (e.g., using specific branded products / kept separate on the plate) and the type of crockery and cutlery used.  

NHS Highland intranet access required for these documents: 

• Meal Plan 1 (1,400 kcal) 
• Meal Plan 2 (1,600 kcal)
• Meal Plan 3 (1.800 kcal)
• Meal Plan 4 (2,000 kcal)
• Meal Plan 5 (2,200 kcal)
• Meal Plan 6 (2,400 kcal)

Management of mealtimes can be a very difficult and emotionally exhausting experience for young people, parents/carers and staff. Young people may be struggling with intrusive thoughts and difficult feelings about food and the impact of this on weight/ body image. This is a brief guide for staff, to support children and young people at meal and snack times. Meal supervision may be provided by a member of the ward nursing team, CAMHS, parent/carer or other informed family member (as per individual care plan).

Outlined below are details of some of the behaviours you may encounter, and guidance on how to respond.

Mealtime strategies

• Remain Calm. Children and young people will pick up anxiety which can make them more anxious.
• Be Confident. The more confident you appear the more reassured the young person will feel.
• Be Consistent. All members of the team should follow the agreed meal plan, and not get into negotiations around this.
• Be Compassionate. Understand that the young person is doing something that is very difficult and frightening for them.

There are strategies that families and staff can use to reduce stress and anxiety at the table:

• Create a positive atmosphere that focuses on the social aspect of meals e.g. by talking about non-food related topics.
• Eat together, where this is possible (this of course may not be possible for staff).
• Avoid sensitive topics e.g. food, weight, calories, appearance.
• Some patients will find praise helpful e.g. saying well done, others will really struggle with praise. It is helpful to ask the person what they find most useful.
• Use distraction to draw attention away from the meal. Use strategies that work for the young person and ask what works for them e.g. telling stories, crossword puzzle, watching a favourite show.
• The use of a meal time passport may be useful – discuss further with CAMHS.
• Use short, supportive phrases in your own words e.g. keep going, you can do it, your almost there or you need to complete this meal.
• Stay focused on completing the meal and remain Calm - Confident - Consistent – Compassionate.

Encourage meal completion

It can be difficult to know how to respond to the young person’s resistance at mealtimes and staff and parents/carers can often feel very powerless in being able to get them to eat.

Repeat helpful phrases in a neutral, calm, confident and kind tone, whilst giving the young person a clear message that there will be no negotiation on the meal plan, and that you (and the team) are in charge. If they attempt to engage you in arguing or negotiating about the meal, give them a clear message that you are not prepared to discuss this.

Time management

Recommended mealtimes and post meal supervision should be provided as below:

Post meal support and supervision

Post meal supervision is essential in preventing or minimising young people engaging in harmful and purging behaviours e.g. self-induced vomiting, exercising, hiding food.

For many people the time after a meal can be more stressful than the meal itself. They may feel distress and may experience physical pain from eating more than they are used to. To support young people at these times you might want to use fun and interesting activities and distractions. You might want to plan with a young person the kinds of activities they can do alone or with you to support them after each meal and snack.

Outlined below are details of some of the behaviour you may have to deal with and tips on how to respond to this.

Management of physical activity

It is important to remember that any energy that the young person takes in though eating is conserved to stabilise their physical health. A young person being treated for anorexia should engage in minimal physical activity whilst on the ward, however this is common struggle for patients.

Engaging with a young person with anorexia

Anorexia can be powerful at pushing the usual boundaries that staff keep in their relationships with patients. The following are behaviours that may indicate that this is happening:

Mealtime management printable document

Patients should be discharged from the ward as soon as the goals for admission have been met, and their physical health is stable enough for safe discharge. Discharge planning involves multidisciplinary discussion including both the Medical Consultant and CAMHS Consultant Psychiatrist, alongside the eating disorder team members. It is important that discharge planning is started as soon as possible to avoid unnecessary delays.

Discharge may be to a specialist mental health unit e.g. Dudhope YPU (<18 years old), Eden Unit (≥18 years old), or the community. This decision should be made after the following factors have been considered:

• The original aims for admission. Have these been met?
• The current physical health of the patient, and any continuing medical requirements.
• Nutritional status, method of feeding and monitoring.
• Mental health supports required.
• The family and individual’s needs, circumstances and preferences.
• The capacity of the CAMHS Inpatient or Intensive Treatment service to manage the physical risk.

• Medical Emergencies in Eating Disorders: Guidance on Recognition and Management (MEED). college-report-cr233-medical-emergencies-in-eating-disorders-(meed)-guidance.pdf
• SIGN 164 Eating Disorders SIGN 164 Eating disorders Revised August 2022
• NICE Eating Disorders: Recognition and Treatment Eating disorders: recognition and treatment
• National Specification for the Care and Treatment of Eating Disorders in Scotland national-specification-care-treatment-eating-disorders-scotland.pdf
• BAPEN Position Statement on Electrolyte and Vitamin Replacement in Adult Patients with Severe Malnutrition, Including those with Eating Disorders and Other Related Conditions electrolyte-and-vitamin-replacement.pdf
• Children and Young People (Scotland) Act 2014 
• Mental Health (Care and treatment) (Scotland) Act 2003 

• AN: Anorexia nervosa
• ARFID: Avoidant restrictive food intake disorder
• ASC: Autism spectrum conditions
• BMI: Body mass index
• BP: Blood pressure
• BPM: Beats per minute
• CAMHS: Children and Adolescent Mental Health Service
• CYP: Children and young people
• ECG: Electrocardiogram
• ED: Eating disorder
• HCU: Highland Children's Unit
• HR: Heart rate
• IBD: Inflammatory bowel disease
• m%BMI: Median percentage BMI
• MDT: Multidisciplinary team
• MEED: Medical emergencies in eating disorders
• NGT: Nasogastric tube
• OCD: Obsessive compulsive disorder
• OSFED: Other specific feeding or eating disorder
• PEACE pathway: Pathway for Eating Disorders and Autism Developed from Clinical Experience
• WCC: White cell count
• YPU: Young Person Unit