1. Medical Assessments in Adolescence
Junior MaRSiPAN
Dr Mark Anderson

3. 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

4. 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

5. 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

6. Newcastle routes of referral
CYPS (CAMHS) GP
Emergency department
Mostly via myself

7. 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!)

8. 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

9. Measurements Percentage median BMI Recent weight loss >85% 80-85%
70-80%
<70%
Recent weight loss
No change
Up to 500g/week for 2 weeks
g/week for 2 weeks
>1kg for 2 weeks

10. Cardiovascular 1 Heart rate (awake) Cool peripheries >60 bpm

11. Cardiovascular 2 Blood pressure Syncope Normal <2nd centile
<0.4th centile
Syncope
No symptoms
Presyncopal symptoms
Occasional syncope with postural drop in BP
Recurrent syncope with marked postural drop

12. Cardiovascular 3 Arrhythmia ECG changes Normal Irregular heart rhythm
QTc <450ms
QTc <450ms and taking QT prolonging medication
QTc >450ms
QTc >450ms and evidence of arrhythmia or electrolyte disturbance

13. Other physiological parameters
Hydration
Not dehydrated
Mild dehydration
Moderate dehydration or peripheral oedema
Severe dehydration
Temperature
<36°C
<35°C

14. Biochemical abnormalities
Hypophosphataemia
Hypokalaemia
Hyponatraemia
Hypocalcaemia
Severe abnormalities of above

15. Calorie intake Moderate restriction or bingeing
Severe restriction (<50% of requirement)
Purging
Acute food refusal or <600kcal/day

16. Activity & exercise No uncontrolled exercise
Mild uncontrolled exercise (<1h/day)
Moderate uncontrolled exercise (1-2h/day)
Severe uncontrolled exercise (>2h/day)

17. 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

18. 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

19. Co-morbidities Deliberate self harm Suicidal ideation
Other major psychiatric co-diagnosis

20. 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”

21. 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

22. 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

23. Longer term issues
General health
Bone health

24. Bones Low bone mineral density Critical time
Risk of later osteoporosis
Back pain
Chronic ill health

25. Bones Nutrition Hypogonadism Relative hypercortisolaemia Low IgF1
Weight and nutrition improve BMD
Residual defect left

26. Bones Possible options OCP (high dose OE) Bisphosphonates Low dose OE
Transdermal OE
Calcium/Vitamin D

27. 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

28. Results BMD change

29. 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

30. Recommendations DEXA scan Commence OE replacement ?when
Who should do this/monitor progress
What happens >18 years of age
What about the boys?

31. Conclusions Acute management Good liaison Easy for <16 year old
Need to support year olds
Long term input
Bones and future health

32. Questions?

33. 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