GP Report

<span class="grab-post-meta-value id-163 key-intro_tables"><table>
<tbody>
<tr>
<td>
<h4>Weight gain is normal in growing children and adolescents. Any weight LOSS should be taken seriously.</h4>
</td>
<td>This report is part of FYI (Feed Your Instinct), an online family early intervention resource for parents who are concerned about their child’s eating difficulties, behaviours that interfere with weight or body dissatisfaction (or a combination of these). It has been provided because a family member has indicated that their child is displaying the above early warning signs which may indicate an eating disorder.</td>
</tr>
<tr>
<td>
<h4>It is important to take parents' concerns seriously, as they see their child's behaviours every day. The young person may not recognise a problem.</h4>
</td>
<td>
<p>It is imperative to recognise when a young person may have an eating disorder, as it is a severe mental illness which has serious medical complications. Many eating disorder diagnoses are missed, delaying essential treatment and potentially increasing the severity and duration of the illness. Sudden weight loss, even in overweight or normal weight children and adolescents can be dangerous and requires medical assessment.</p>
</td>
</tr>
<tr>
<td>
<h4>It is not safe to watch and wait. Early identification of an eating disorder is vital and can save a life.</h4>
</td>
<td>
<p>A GP’s role is critically important to provide an assessment of current medical risk. This includes conducting investigations to look for alternative causes and complications of weight loss or to exclude other serious illnesses. Eating disorders can be complicated to identify as investigations may be NORMAL in a child or young person who is very unwell. Therefore diagnosis is made primarily through obtaining a history and examination.</p>
<p>The aim of the medical assessment and investigations is to provide critical information which will help GP’s direct the young person and their family to access the right level of support via a care pathway. If there is some uncertainty about what is the right pathway, you can directly contact Eating Disorder Clinical Nurse Consultants at Monash, Austin and the Royal Children’s Hospital.</p>
<p>GP’s can refer immediately to a local mental health service via centralised triage for the local area if a young person is engaging in self harm or expressing suicidal thoughts, or if a young person has a suspected eating disorder and is medically safe. The mental health service can work collaboratively with GP’s to provide further advice, assessment, support and treatment.</p>
</td>
</tr>
</tbody>
</table></span>

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<tr>
<td>
<h4><span style="font-weight: 400; color: #ff0000;">Red Pathway – Immediate redirection to emergency department</span></h4>
</td>
<td>
<p><strong>Cardiac instability:<br />
</strong>Refer ViCTOR charts for age specific observations:</p>
<p>12-18yo:</p>
<p><a href="https://www.victor.org.au/victor-charts/" target="_blank" rel="noopener">www.victor.org.au/victor-charts/</a></p>
<p>5-11yo:</p>
<p><a href="https://www.victor.org.au/victor-charts/" target="_blank" rel="noopener">www.victor.org.au/victor-charts/</a></p>
</td>
<td>
<p>Heart rate (pulse):  under 50 bpm</p>
<p>Blood pressure 80/50mm Postural changes ( lying to standing) Tachycardia 30 bpm</p>
<p>Postural Blood Pressure drop 20 mm</p>
<p>Recurrent syncope</p>
<p>Arrhythmia (including sinus bradycardia less than 50bpm)</p>
</td>
</tr>
<tr>
<td> </td>
<td><strong>Electrolyte changes:</strong></td>
<td>
<p>Hypokalaemia -Present</p>
<p>Abnormal renal function</p>
</td>
</tr>
<tr>
<td> </td>
<td><strong>Other:</strong></td>
<td>Hypothermia 35.5 deg C</td>
</tr>
</tbody>
</table></span>

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<tbody>
<tr>
<td> </td>
<td><strong>Screening, Examination or investigation</strong></td>
<td><strong>Purpose</strong></td>
</tr>
<tr>
<td>
<h4>Acute complications</h4>
</td>
<td>ECG</td>
<td>Check bradycardia; prolonged QTc</td>
</tr>
<tr>
<td> </td>
<td>Electrolytes</td>
<td>Potential hypokalaemia if purging;<br />
hyponatraemia if water loading;<br />
impaired renal function if dehydrated<br />
Rarely may reveal other medical cause of weight loss eg Addison's disease</td>
</tr>
<tr>
<td> </td>
<td>LFT</td>
<td>May have biliary sludging with increased bilirubin</td>
</tr>
<tr>
<td> </td>
<td>Calcium/Magnesium/Phosphate</td>
<td>Abnormalities with refeeding; low calcium if low albumin</td>
</tr>
<tr>
<td> </td>
<td>BSL</td>
<td>Hypoglycaemia<br />
Excludes diabetes as a cause of weight loss</td>
</tr>
<tr>
<td> </td>
<td>FBC</td>
<td>Nutritional anaemia ( micro or macrocytic)<br />
Neutropenia<br />
Low platelets may occur with malnutrition</td>
</tr>
<tr>
<td>
<h4>To detect other possible cause or comorbidity</h4>
</td>
<td>ESR</td>
<td>Inflammatory bowel disease<br />
Rheumatological disease<br />
Chronic infection</td>
</tr>
<tr>
<td> </td>
<td>TFT</td>
<td>Abnormalities may reflect sick euthyroid or hyperthyroid as rare cause of weight loss</td>
</tr>
<tr>
<td> </td>
<td>Coeliac screen</td>
<td>May present with weight loss</td>
</tr>
<tr>
<td>Determine chronic complications of malnutrition</td>
<td>B12/folate<br />
Iron studies<br />
Vitamin D<br />
FSH/LH/Oestradiol</td>
<td>Low levels reflect malnourishment<br />
If amenorrhoea post puberty</td>
</tr>
<tr>
<td> </td>
<td>Bone density (not urgent)</td>
<td>Determine effect of malnourishment on growing bones or after period of a menorrhoea. (PBS subsidy if over 6 months)<br />
Bone age x-ray necessary in conjunction with bone density for under 18yo</td>
</tr>
</tbody>
</table></span>

<span class="grab-post-meta-value id-163 key-notes_for_gp"><h4>Further notes for GPs:</h4>
<ul>
	<li>If parents are concerned it is essential to take their concerns seriously, as they see their childs behaviours every day and are an important resource for treatment.</li>
	<li>Parents are essential resources and are responsible for making sure a young person with eating and body image problems, or an eating disorder, is safe and complies with vital treatment. Parents should be included for a period of all consultations, with clear boundaries around confidentiality and risk.</li>
	<li>Unfortunately there is not one conclusive examination or investigation which clearly indicates at eating disorder. Results should be considered in a holistic manner taking into account the history and family concerns.</li>
	<li>Regular appointments and ongoing assessment is essential. Young people can become medically compromised quickly and unpredictably.</li>
	<li>Sustained weight loss of greater than 500gm-1kg per week for any young person is concerning, regardless of their actual weight.</li>
</ul></span>

<span class="grab-post-meta-value id-163 key-notes_for_parents"><h4>Further notes for Parents:</h4>
<ul>
	<li>It is advisable to book a double GP appointment to allow sufficient time for a comprehensive assessment.</li>
	<li>It can be helpful to speak to GP before the appointment to alert them of your concerns.</li>
	<li>If you have a record of your childs height or weight development for any period of time from birth up until the current day (such as a yellow book), bring this to the appointment as it has vital information that can aid the assessment.</li>
	<li>It may be useful to determine how confident your GP is in identifying eating disorders via prior phone call, as not all GPs have expertise in this specialist area.</li>
</ul>
<p>This report is based on the following clinical guidelines:</p>
<p>RANZCP clinical practice guidelines for the treatment of eating disorders, 2014<br />
<a href="https://www.ranzcp.org/Files/Resources/Publications/CPG/Clinician/Eating-Disorders-CPG.aspx" target="_blank" rel="noopener">https://www.ranzcp.org/Files/Resources/Publications/CPG/Clinician/Eating-Disorders-CPG.aspx</a></p>
<p>NICE guidelines (2004)<br />
<a href="http://www.nice.org.uk/guidance/cg9/evidence/full-guideline-243824221" target="_blank" rel="noopener">http://www.nice.org.uk/guidance/cg9/evidence/full-guideline-243824221</a></p></span>

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Weight gain is normal in growing children and adolescents. Any weight LOSS should be taken seriously.

This report is part of FYI (Feed Your Instinct), an online family early intervention resource for parents who are concerned about their child’s eating difficulties, behaviours that interfere with weight or body dissatisfaction (or a combination of these). It has been provided because a family member has indicated that their child is displaying the above early warning signs which may indicate an eating disorder.

It is important to take parents' concerns seriously, as they see their child's behaviours every day. The young person may not recognise a problem.

It is imperative to recognise when a young person may have an eating disorder, as it is a severe mental illness which has serious medical complications. Many eating disorder diagnoses are missed, delaying essential treatment and potentially increasing the severity and duration of the illness. Sudden weight loss, even in overweight or normal weight children and adolescents can be dangerous and requires medical assessment.

It is not safe to watch and wait. Early identification of an eating disorder is vital and can save a life.

A GP’s role is critically important to provide an assessment of current medical risk. This includes conducting investigations to look for alternative causes and complications of weight loss or to exclude other serious illnesses. Eating disorders can be complicated to identify as investigations may be NORMAL in a child or young person who is very unwell. Therefore diagnosis is made primarily through obtaining a history and examination.

The aim of the medical assessment and investigations is to provide critical information which will help GP’s direct the young person and their family to access the right level of support via a care pathway. If there is some uncertainty about what is the right pathway, you can directly contact Eating Disorder Clinical Nurse Consultants at Monash, Austin and the Royal Children’s Hospital.

GP’s can refer immediately to a local mental health service via centralised triage for the local area if a young person is engaging in self harm or expressing suicidal thoughts, or if a young person has a suspected eating disorder and is medically safe. The mental health service can work collaboratively with GP’s to provide further advice, assessment, support and treatment.

Red Pathway – Immediate redirection to emergency department

Cardiac instability:
Refer ViCTOR charts for age specific observations:

12-18yo:

www.victor.org.au/victor-charts/

5-11yo:

www.victor.org.au/victor-charts/

Heart rate (pulse): under 50 bpm

Blood pressure 80/50mm Postural changes ( lying to standing) Tachycardia 30 bpm

Postural Blood Pressure drop 20 mm

Recurrent syncope

Arrhythmia (including sinus bradycardia less than 50bpm)

Electrolyte changes:

Hypokalaemia -Present

Abnormal renal function

Other:

Hypothermia 35.5 deg C

Amber Pathway – Urgent referral to local specialist medical service and mental health service

Abnormal other investigations (Neutropenia, Thyroid Function Test)
Ongoing weight loss (move to red pathway if more than 500gm-1kg per week for consecutive weeks)Amenorrhea (change of menstrual pattern because of weight loss)Monitor weight, vital signs (including postural changes) with pulse rate and blood pressure regularly (weekly-fortnightly)

Green pathway – Referral to local specialist ED service or mental health service

Medically stable but warning signs present.

Mental Health assessment to determine if Eating Disorder present and begin evidence based treatment.

Monitor weight, vital signs (including postural changes) with pulse rate and blood pressure regularly.

	Screening, Examination or investigation	Purpose
Acute complications	ECG	Check bradycardia; prolonged QTc
	Electrolytes	Potential hypokalaemia if purging; hyponatraemia if water loading; impaired renal function if dehydrated Rarely may reveal other medical cause of weight loss eg Addison’s disease
	LFT	May have biliary sludging with increased bilirubin
	Calcium/Magnesium/Phosphate	Abnormalities with refeeding; low calcium if low albumin
	BSL	Hypoglycaemia Excludes diabetes as a cause of weight loss
	FBC	Nutritional anaemia ( micro or macrocytic) Neutropenia Low platelets may occur with malnutrition
To detect other possible cause or comorbidity	ESR	Inflammatory bowel disease Rheumatological disease Chronic infection
	TFT	Abnormalities may reflect sick euthyroid or hyperthyroid as rare cause of weight loss
	Coeliac screen	May present with weight loss
Determine chronic complications of malnutrition	B12/folate Iron studies Vitamin D FSH/LH/Oestradiol	Low levels reflect malnourishment If amenorrhoea post puberty
	Bone density (not urgent)	Determine effect of malnourishment on growing bones or after period of a menorrhoea. (PBS subsidy if over 6 months) Bone age x-ray necessary in conjunction with bone density for under 18yo

Further notes for GPs:

If parents are concerned it is essential to take their concerns seriously, as they see their childs behaviours every day and are an important resource for treatment.
Parents are essential resources and are responsible for making sure a young person with eating and body image problems, or an eating disorder, is safe and complies with vital treatment. Parents should be included for a period of all consultations, with clear boundaries around confidentiality and risk.
Unfortunately there is not one conclusive examination or investigation which clearly indicates at eating disorder. Results should be considered in a holistic manner taking into account the history and family concerns.
Regular appointments and ongoing assessment is essential. Young people can become medically compromised quickly and unpredictably.
Sustained weight loss of greater than 500gm-1kg per week for any young person is concerning, regardless of their actual weight.

Further notes for Parents:

It is advisable to book a double GP appointment to allow sufficient time for a comprehensive assessment.
It can be helpful to speak to GP before the appointment to alert them of your concerns.
If you have a record of your childs height or weight development for any period of time from birth up until the current day (such as a yellow book), bring this to the appointment as it has vital information that can aid the assessment.
It may be useful to determine how confident your GP is in identifying eating disorders via prior phone call, as not all GPs have expertise in this specialist area.

This report is based on the following clinical guidelines:

RANZCP clinical practice guidelines for the treatment of eating disorders, 2014
https://www.ranzcp.org/Files/Resources/Publications/CPG/Clinician/Eating-Disorders-CPG.aspx

NICE guidelines (2004)
http://www.nice.org.uk/guidance/cg9/evidence/full-guideline-243824221

These questions relate to a young person's food choices, eating patterns and attitudes towards nutrition.
Have you noticed any of the following?
A change in eating pattern, such as skipping meals	Yes No N/A
Eating alone, eating secretly, or having 'rituals' around food or meal times	Yes No N/A
Avoiding family meals or eating with others	Yes No N/A
Hiding, or secretly throwing away uneaten food	Yes No N/A
Leaving the table during a meal and avoiding finishing their food	Yes No N/A
Frequently reporting to have eaten elsewhere, or being dishonest about their eating	Yes No N/A
Limiting the variety of foods eaten	Yes No N/A
Eating according to strict food rules, such as no carbohydrates, or no sugar	Yes No N/A
Suddenly becoming vegetarian or vegan	Yes No N/A
Development of food 'intolerances'	Yes No N/A
A strong preference for 'diet' or 'low fat' products	Yes No N/A
Frequently talking about losing weight, or making comments about being 'fat'	Yes No N/A
Displaying a high level of concern about the calorie content of food	Yes No N/A
A strong focus on what others are eating, interest in cooking or interest in cookbooks without actually eating	Yes No N/A
Evidence of over eating (large amounts of food disappearing from household, hidden wrappers and packaging)	Yes No N/A
Finding it hard to stop eating once they have started	Yes No N/A
A history of 'picky' eating	Yes No N/A
Rigidity around food preparation and eating such as cutting food into tiny pieces, or 'hovering' in the kitchen whilst others are cooking	Yes No N/A
Anxiety, irritability, anger and hostility at mealtimes	Yes No N/A

These questions relate to a young person's physical health and any unhelpful behaviors they may be participating in.
Have you noticed any of the following?
A fluctuation in weight over a few weeks (weight gain or loss)	Yes No N/A
Significant weight change as a result of illness, travel or increased participation in sport and exercise	Yes No N/A
A growth spurt without any weight gain	Yes No N/A
Any evidence of vomiting after meals	Yes No N/A
Excessive, obsessive or ritualistic exercise	Yes No N/A
Having problems sitting still, and standing, twitching or pacing whenever possible	Yes No N/A
Evidence of exercising in secret (e.g. in the middle of the night or in their bedroom)	Yes No N/A
Engaging in intense exercise with no pleasure	Yes No N/A
Exercising to compensate for eating	Yes No N/A
Packets of diet pills or laxatives	Yes No N/A
Constipation, or unexplained stomach pains	Yes No N/A
Cold hands, or feet, or regular complaints of feeling cold	Yes No N/A
Fainting or complaining of dizziness	Yes No N/A
A delayed onset of periods (if female), or a loss of menstrual cycle	Yes No N/A

These questions relate to thinking patterns and personality traits of a young person.
Have you noticed any of the following?
Very low self-esteem	Yes No N/A
Rigid, black and white thinking (e.g. good/bad or right/wrong)	Yes No N/A
Increased perfectionism	Yes No N/A
Body dissatisfaction e.g. a strong conviction they need to be thinner	Yes No N/A
A strong focus on perceived flaws of their body or a particular part of their body	Yes No N/A
Constantly seeking reassurance about body size	Yes No N/A
Obsessive body checking e.g. weighing, pinching, excessive time in front of the mirror	Yes No N/A
An interest in weight loss blogs, websites, magazines, books or images of thin people	Yes No N/A

These questions relate to changes in the way a young person is interacting with others.
Have you noticed any of the following?
Increased social isolation or withdrawal	Yes No N/A
Perceiving others to be judgemental	Yes No N/A
Experiencing difficulty talking about emotions	Yes No N/A

FEEDYOURINSTINCT

Eating

Wellbeing

Thinking

Feeling

Weight gain is normal in growing children and adolescents. Any weight LOSS should be taken seriously.

It is important to take parents' concerns seriously, as they see their child's behaviours every day. The young person may not recognise a problem.

It is not safe to watch and wait. Early identification of an eating disorder is vital and can save a life.

Red Pathway – Immediate redirection to emergency department

Amber Pathway – Urgent referral to local specialist medical service and mental health service

Green pathway – Referral to local specialist ED service or mental health service

Acute complications

To detect other possible cause or comorbidity

Further notes for GPs:

Further notes for Parents:

FEEDYOURINSTINCT

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