A registrar-level reference for the child/adolescent presenting with a possible eating disorder: assessment, admission criteria, refeeding syndrome risk and monitoring, the nasogastric feeding/meal plan protocol, ward management, and the pathway to nutritional rehabilitation and discharge.
Queensland Health QH-GDL-961:2020CYMHS Eating Disorders Program
Read first. Decision-support, not a substitute for senior medical, psychiatric (CYMHS/consultation-liaison) or dietetic input. Confirm every fluid, supplement and feeding-rate order against your local protocol and CREDD before prescribing. Medical and mental-health risk should be assessed in parallel from presentation — this is not a purely medical or purely psychiatric condition.
This guideline assists staff in Child and Youth Mental Health Services (CYMHS), Emergency Departments, mental health inpatient units and paediatric medical wards assessing a child/adolescent with a possible eating disorder, and deciding placement, treatment and care. Medical and mental-health risk are assessed in parallel — the medical team retains clinical governance while the child is on a medical ward, with CYMHS/consultation-liaison (C/L) providing treatment planning support throughout.
Guiding principle
The least restrictive, safe treatment alternative is provided wherever possible, with clear communication, psycho-education and shared decision-making with the child/adolescent and family/carers throughout.
First presentation
Other medical causes for malnutrition or disordered eating must be excluded before proceeding on an eating-disorder pathway.
Two-phase model
Nutritional resuscitation (medical crisis, §4-6) comes first if medically indicated, followed by nutritional rehabilitation (§7) once medically stable, then transfer to outpatient/community care.
2
Assessment — history, examination, investigations
History
Attitudes to weight/shape: healthy weight belief, fear of weight gain, body dissatisfaction, weighing frequency
Severe family stress/strain; suicidality/self-harm unmanageable as outpatient
Bulimia Nervosa — medical admission
Serum potassium <3.2 mmol/L
Serum chloride <88 mmol/L
Oesophageal tears; haematemesis
Intractable vomiting
Cardiac arrhythmia including QTc >450 msec
Hypothermia (temp <35.5°C)
Severe family stress/strain; suicidality/self-harm unmanageable as outpatient
Mental health inpatient admission — consider if any of
Family/functional
Severe family stress or strain; eating-disorder behaviours significantly impacting functioning.
Risk
Behaviours likely to put the child/adolescent at medical risk; moderate-high suicidal risk.
Recovery-limiting
Agitation, depression or obsessionality preventing nutritional recovery; any other psychiatric condition needing hospitalisation regardless of eating-disorder diagnosis.
4
Refeeding syndrome — risk & monitoring
the first 2 weeks of refeeding carry the greatest risk, by any route
Refeeding syndrome is a metabolic derangement (electrolyte shifts, vitamin deficiency, sodium/fluid retention) triggered by reintroducing nutrition after prolonged starvation. Changes typically occur within 3-4 days but can present up to 2 weeks in, regardless of oral or enteral route. Recognising who is at risk is the most important step.
High-risk criteria (Table 4)
High risk — any ONE of
BMI <5th centile
Weight loss >15% in previous 3-6 months
Insufficient oral intake to sustain function for 10 days
Hypophosphataemia, hypomagnesaemia, hypocalcaemia or hypokalaemia prior to refeeding
High risk — TWO or more of
BMI between 5th and 10th centile
Weight loss >10% in previous 3-6 months
Insufficient oral intake to sustain function for 5-7 days
Multivitamin 1 tab daily (ongoing) · Thiamine 100 mg daily for 5 days · Phosphate 500 mg twice daily until on full meal plan and refeeding risk is low. Hypophosphataemia is the hallmark of refeeding syndrome and may be accompanied by hypokalaemia, hypomagnesaemia, hypoglycaemia, and sodium/fluid retention — monitor for respiratory, muscular and cardiac changes in anyone receiving PO₄³⁻/K⁺/Ca²⁺/Mg²⁺ replacement.
Avoid IV fluid boluses in this population — IV rehydration should occur only after consultant/senior medical review, to avoid fluid overload and cardiac compromise.
5
The feeding protocol — NG tube & meal plans
nutritional resuscitation in medical crisis
If the child/adolescent declines a recommended NG tube, start a half meal plan (oral only) and progress by 500 kcal/2000 kJ every 2-3 days until the full meal plan is reached, with close nursing supervision for compensatory behaviours.
If at risk of refeeding syndrome — staged NG protocol (Table 6)
Day 1-2
Standard start
Continuous NG feed 80 mL/hr Nutrison Standard (1 cal/mL) ≈ 2000 kcal/8400 kJ/day. Encourage oral intake if possible; prompt dietetic review; sips of water allowed.
Day 1, if higher-risk
Lower-calorie start
If phosphate <1.0 mmol/L, dehydrated at presentation (tachycardia, dry membranes, high urine SG, raised urea/creatinine/albumin), or BMI <14: commence continuous Glycolyte 80 mL/hr (1340 kcal/5620 kJ over 24 h) instead — this group is at higher refeeding-syndrome risk.
Day 2-15
Transition to half meal plan
Once HR >50 bpm during the day AND electrolytes stable on daily bloods (Chem20 incl. Ca²⁺/Mg²⁺/PO₄³⁻): cease daytime NG feeds, commence half meal plan (1800 kcal/7600 kJ), and start overnight NG feeds 100 mL/hr over 10 h (1 cal/mL Nutrison Standard).
Ongoing
Full meal plan
Once HR >50 bpm overnight AND electrolytes stable (bloods twice weekly) AND core temp >35.5°C overnight: cease overnight feeds, commence full meal plan (3200 kcal/13400 kJ). If weight gain <0.5-1 kg/week with no other cause found, consider a high-energy meal plan (3600 kcal/15000 kJ).
If NOT at risk of refeeding syndrome
Start
Half meal plan + overnight NG feeds, totalling 2800 kcal/11800 kJ/day.
Progress
Once 100% of the half meal plan is achieved for ≥2 consecutive days without needing a bolus, progress to the full meal plan with no overnight NG feeds required.
Why bolus options are calorie-loaded
Every meal/snack should have a nominated bolus option (given if the meal isn't finished in time) — ideally worth ≥10% more kcal/kJ than the oral option (full/high-energy plans), so completing the meal orally is always the path of least resistance. Kilocalorie/volume figures should not be shown to the child/adolescent, to avoid heightening anxiety and resistance.
6
Ward management — bed rest, meal support, the Mental Health Act
Activity & leave
Leave is not recommended while medically compromised; transport for investigations by wheelchair with nurse escort
Bed rest (bed or chair) while medically compromised (§3 criteria)
May lift bed rest once vitals improved, non-symptomatic orthostatic changes, HR >50 bpm overnight, and core temp >35.5°C, at treating-team discretion
Meal-time support rules
Main meals consumed within 30 minutes; snacks within 15 minutes
No negotiation around prescribed meal plans (except a documented medical/religious/cultural reason)
No special diets approved without supporting medical/longitudinal history
1:1 supervision if treatment isn't progressing or concerns persist
Toilet before meals; monitor if toileting occurs within 30 min after a meal (purging risk)
Post-meal support: 60 minutes after main meals, 30 minutes after snacks
Use of the Mental Health Act 2016 (Qld)
Less restrictive way, first
Consider Gillick competence for the child/adolescent's own capacity to consent, or parental/guardian consent, before involuntary treatment. A parent/guardian cannot consent to seclusion, restraint, or ECT on a minor. An authorised doctor may issue a Treatment Authority only if treatment is necessary and no less-restrictive option meets the minor's needs. Contact the hospital C/L team or local CYMHS for advice before using the MHA, and document the rationale clearly.
Seclusion, mechanical restraint and physical restraint are a last resort only, used per MHA/Chief Psychiatrist Policy — trauma-informed, least-restrictive alternatives come first. Acute sedation: offer oral sedation before any parenteral route; extra caution in young people/frail or medically compromised patients (higher toxicity risk).
7
Nutritional rehabilitation
once medical crisis has resolved
Indications
Low refeeding-syndrome risk; nutritionally resuscitated (deficiencies now supplement-managed) but remains unwell; compensatory behaviours not fully manageable by family/staff; significant weight gain still needed (>15 kg) that outpatient care can't achieve in time; or ≥50% of intake still via NG/supplement/bolus.
Setting
Paediatric medical ward or mental health inpatient unit, per local service policy.
Per Children's Early Warning Tool (CEWT) or local equivalent
Weight (hospital gown, post-void)
Twice weekly, target 0.5-1 kg/week gain
Urinalysis / fluid balance
As clinically indicated
Medication administration
Observed directly at time of dose
Watch for signs of bingeing (food requested from visitors, food missing from ward supplies/other patients' trays) alongside routine monitoring.
8
Expected Body Weight (EBW)
a moving target — recalculate as the child grows
Unlike adults, a child/adolescent is still growing, so EBW must be recalculated with increasing age and height throughout treatment — it is not a static number.
Preferred method: plot the child's weight on the same percentile they were tracking on their premorbid growth chart (by age/sex), if previous height/weight measurements are available.
If premorbid data unavailable:EBW = 50th-percentile BMI (for age/gender) × Height(m)². For very tall/short children (>90th or <10th percentile for height), match percentiles instead (e.g. >90th height → use 75th weight percentile or higher).
EBW as a discharge target
Transfer to outpatient care generally requires attainment of at least 85% of EBW — this threshold may need to be higher if the child/adolescent is not going to a specialist eating disorder service or a structured program such as Family Based Therapy for Anorexia Nervosa.
9
Discharge & escalation
Discharge home (no transfer to MH unit) if
Consistently completing the full meal plan, with or without supplements
NG feeds NOT required to sustain or increase weight
Assessed as physically stable by the medical team
Parents/carers can support a meal with minimal/no staff support (demonstrated on ward leave)
Comprehensive outpatient follow-up plan organised via CYMHS/C-L
Transfer to mental health inpatient unit if
Tolerating the feeding regime but needs further prolonged nutritional rehabilitation
Other mental health issues (from low weight/BMI or psychosocial factors) needing further parental/carer empowerment before safe outpatient care
Ongoing nutritional resuscitation stops once
Observations are within acceptable (if low-normal) limits for age/sex/height; electrolytes and BGL are normal without supplementation; no cardiac abnormality (sinus rhythm, no monitoring needed); low refeeding-syndrome risk; weight increasing from admission baseline; and either mental-health admission is arranged, or follow-up is booked within 72 hours of discharge.
Who to call
Local CYMHS / hospital C/L team
Refer at admission for urgent assessment and joint treatment planning with the medical team.