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Medical Assessments in Adolescence

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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

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