Junior Marsipan

Report
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

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