Paeds - Thin Teenager Flashcards
What are the risks associated with rapid weight loss?
- Refeeding syndrome
- Hypoglycaemia (low blood sugar)
- Risk of infection
- Arrhythmias
What is refeeding syndrome?
Refeeding syndrome describes the metabolic abnormalities which occur on feeding a person following starvation
Consequences:
- Hypophosphataemia (low phosphate) - can precipitate respiratory arrest due to diaphragm not being able to contract + myocardial dysfunction
- Hypokalaemia (low potassium)
-
Hypomagnesaemia
- may predispose to torsades de pointes
- Abnormal fluid balance - periperal oedema
-
Organ failure (ultimate consequence of the above)
- Cardiac arrhythmias
- Congestive heart failure - severe oedema during refeeding
- Cardiac failure
What criteria identify patients as being at risk
of refeeding syndrome?
High-risk if 1 or more of the following:
- BMI < 16 kg/m2
- Inintentional weight loss > 15% over 3-6 months
- Little nutritional intake > 10 days
- Hypokalaemia, hypophosphataemia or hypomagnesaemia prior to feeding
High-risk if 2 or more of the following:
- BMI < 18.5 kg/m2
- Unintentional weight loss > 10% over 3-6 months
- Little nutritional intake > 5 days
- Hx of:
- alcohol abuse
- drug therapy including insulin
- chemotherapy
- diuretics
- antacids
BMI is not as accurate in children, so an alternative measure is used, what is it?
Weight for Height Ratio
- Weight for height = (weight of the pt (Kg) / weight of a normal child of the same height) x 100
- > 90% = normal
- < 75% = severe malnutrition
What questions might be important in a Hx of a young patient who rapidly losing weight and won’t eat?
Rule out organic causes!! - ask about:
- Abdominal pain, dyspepsia
- Bloating
- Fever, vomiting
- Diarrhoea, malaena, constipation, blood in stool
Psych:
- Perception: ‘feeling fat’, pre-occupation with calories, focussed on clothes size, perfectionist body complaints
- Actions: excess exercise, hiding food, purging / intentional vomiting, vegan diet
- FHx of eating disorder or mental illness
- Drugs: laxative use, recreational, smoking, alcohol
- Menstual Hx
What conditions can cause rapid weight loss in a child / adolescent?
Endocrine:
- Hyperthyroidism
- T1DM
- Addisons
GI:
- Oesphageal problems e.g. achalasia
- Coeliac disease
- Inflammatory bowel disease
Psych:
- Anorexia nervosa
- Severe depression / OCD/ autism
Other:
- Juvenile arthritis
- Malignancy
When a patient is at risk of refeeding syndrome, what vitamins are given to prevent this?
Thiamine (B1), vitamin B complex and multivitamins
In a patient with rapid weight loss, they may have fine
fluffy hair appear on their body e.g. cheeks
why is this and what is it called?
Lanugo hair
- Grows in response to the loss of insulating effect of fat tissue
- Is very thin, soft, unpigmented, downy hair
- Normally grows on babies in utero and sheds before birth or shortly after
Which blood test is the best acute assessment of liver function being normal?
Coagulation screen
What is the most common reason for admission to child and adolescent psychiatric wards?
Anorexia nervosa
What is anorexia nervosa?
It is an eating disorder characterised by:
- restriction of caloric intake
- low body weight
- intense fear of weight gain
- body image disturbance
Highest mortality of all psychiatric conditions
How is anorexia nervosa diagnosed?
DSM-5 criteria:
- Restriction of energy intake relative to requirements leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health
- Intense fear of gaining weight or becoming fat, even though underweight
- Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight
What are the features of anorexia nervosa?
Epidemiology:
- 90% of pts = female
- adolescents / young women
Psych:
- calorie restriction relative to requirements
- low body weight (e.g. BMI < 18.5 kg/m2 or BMI below 5th percentile for age)
- fear of weight gain / becoming fat
- disturbed body image (cognitive distortions about weight / shape)
- subjective ‘binge-eating’ episodes (not real binge-eating, but seems like a lot to them)
- purging
- laxative, diuretic or diet pull misuse
- food-occupied thoughts e.g. read menus, read nutritional info
Physiological:
- amenorrhoea
- orthostatic hypotention
- constipation (small amounts of good –> gastric motility slows)
- hypothermia
- cardiac symptoms:
- bradycardia
- hypotension
- cool peripheries
- peripheral oedema
- QTc prolonged, 1st degree heart block, mitral valve prolapse and pericardial effusions
- Electrolyte disturbances:
- hypokalaemia
- low FSH, LH, oestrogens and testosterone –> causes fertility issues
- hypercholesterolaemia
- hypercarotenemia (high beta-carotene –> yellow skin pigementation)
- low T3
- fatigue
- Osteopenia / osteoporosis (if ill for years)
In children and adolescents what is 1st line for anorexia nervosa?
1st line = Anorexia focused family therapy
2nd line = CBT
Which blood electrolyte is most important to monitor if concerned about refeeding syndrome?
Phosphate
