SDMS ID: P2010/0938-001

Policy 01-11AH

Title: NAHS Dietetic Guideline for the Management of Eating

Disorders in paediatric patients

Replaces: N/A
Description: This guideline details the dietetic management of paediatric patients affected
by eating disorders
Target Audience: NAHS Dietitians
Key Words: Dietetic, nutrition, eating disorder, paediatric

Policy Supported: P2010/0717-001 Allied Health Professional Services: Guidelines for the
Prioritisation of Patients

Purpose:
To clarify the nutrition management of paediatric patients affected by eating disorders in inpatient
and outpatient settings
To guide the provision of consistent, best practice nutrition services to paediatric patients affected by
eating disorders in paediatric outpatient clinics
To ensure appropriate outpatient referrals and referral processes for paediatric patients affected by
eating disorders

Definitions:
Paediatric – for the purpose of this guideline a paediatric patient is aged 17 years or under and who lives
with a parent or guardian.

Eating disorder – The most common eating disorders are anorexia nervosa and bulimia nervosa, however
other types of eating disorders also exist.

Anorexia nervosa
Anorexia nervosa is a serious disorder in which a person will starve themselves in an effort to be thin.
Symptoms of anorexia nervosa include:
excessive weight loss
depression
poor self esteem
loss of periods in females
distorted body image
preoccupation with food

NAHS Dietetic Guideline for the Management of Eating Disorders in paediatric patients Policy 01-11AH
May-11
Bulimia nervosa
Bulimia nervosa is an eating disorder in which the person may eat large amounts of food and then make an
effort to either rid their body of the food or use up the kilojoules from the food. Methods to rid the body
of food include vomiting or use of laxatives. Exercising excessively may be a way of using up energy
(kilojoules) consumed.
Symptoms of Bulimia Nervosa include:
secretive binge eating
vomiting after eating
frequent use of laxatives
depression
over-exercising
weight fluctuations

Other forms of eating disorders may often exhibit some but not all of the features of either anorexia or
bulimia nervosa.
Eating disorders often occur during adolescence and young adulthood and can be caused by a number of
different things, particularly psychological factors.
NAHS Dietetic services - Dietitians provide nutrition management and support services to paediatric
patients affected by eating disorders in both inpatient and outpatient settings in accordance with the Allied
Health Professional Services: guidelines for the Prioritisation of Patients: LGH Policy 5-10AH
LGH paediatric inpatient multidisciplinary team (MDT) – are responsible for providing co-ordinated care
and treatment for inpatients. MDT members include psychiatric, medical, nursing, allied health including
dietitian, psychologist, Child and Adolescent Mental Health Service (CAMHS) staff.
Maudsley model - The Maudsley model of family therapy relies on a trained family therapist to work closely
with children and young people and family members to assist affected young people to regain control of
their eating. While the model emphasises the close relationship between individual family therapists and
other health care providers (such as dietitians), according to the model these providers are mainly
responsible for providing information and education to support family therapy rather than direct
counselling and negotiating behavioural changes.1 Discussions amongst the LGH MDT for paediatric eating
disorder patients have indicated that the Maudsley model is the preferred model to be used in managing
paediatric eating disorder patients.
Strategies:
(i) Inpatient management
Dietitians working as part of the MDT actively participate in case conferences and weekly patient review
meetings.
Dietetic input into the multidisciplinary care of affected individuals may include nutrition advice on the
following:
Estimated nutritional requirements (including energy, protein, vitamin, mineral and fluid )
Body Mass Index (BMI) targets
Healthy weight gain targets
Development and monitoring of enteral feed regimes
Identifying and providing advice regarding patients at risk of re-feeding syndrome
Meal plans to meet nutrition requirements
Healthy snack and meal ideas
General nutrition advice

NAHS Dietetic Guideline for the Management of Eating Disorders in paediatric patients Policy 01-11AH
May-11
(ii) Outpatient management
Dietitians working in outpatient settings use the Maudsley model of family therapy to guide the delivery of
nutrition intervention for paediatric patients affected by eating disorders.
Accordingly, the main intervention recommended for use by dietitians working with paediatric patients
affected by eating disorders in outpatient clinics is to provide nutrition education about healthy eating.
Based on the experience of other dietitians working in outpatient paediatric clinics, it is expected that
dietitians may conduct between one and three outpatient visits for patients affected by eating disorders.
The nutrition education topics that may be provided at each visit are outlined below. Dietitians will use
professional judgement to customise service provision where required.
Initial visit - Dietitians will use the Australian Guide to Healthy Eating (AGHE) to educate patients
and their attendant parent/s about age-appropriate healthy eating recommendations. Dietitians will
explain that depending on activity levels, individual differences to AGHE recommendations may apply.
A copy of the AGHE patient handout and a summary of recommended amounts of serves from the
different food groups to consume each day may be provided to patients.
Second visit - A follow up review visit may be scheduled if requested by the patient and agreed to
by the Dietitian. At this visit, the Dietitian will refer to the AHEG recommendations made at the first
visit. Depending on the food and nutrition issues applicable to the client, the dietitian may also
provide education on the following topics:
o Digestion and absorption
o Weight changes
o Understanding appetite
o Metabolism and changes to metabolic rate
o Facts on dieting
o Simple snack ideas
o Normal healthy eating
o Physical and psychological side effects of anorexia/bulimia
Copies of these resources may be found in the NAHS nutrition department paediatric outpatient folder
and online from the Dietitians Association of Australia (DAA) Eating Disorder Interest Group 2007.
Third visit - A third review visit within a 12 month period may be scheduled if requested by the
patient and/or parent and agreed to by the Dietitian. At this visit, the Dietitian will reinforce nutrition
education messages provided at the first two visits and may expand on the topics covered above if
appropriate.
Dietetic input provided by the NAHS dietitians into the multidisciplinary care of affected patients does not
extend to monitoring patients weight nor does it include encouraging or trying to motivate affected
patients to eat as medical professionals and mental health professionals respectively are better placed and
qualified to address these ongoing factors.

Procedure:
Inpatient referrals
Dietitians will generally receive an automatic referral via an Allied Health referral form for providing
individualised nutrition assessment, support, intervention and review for affected patients.
Referral to the paediatric nutrition outpatient clinic
(i) New patients
Only referrals from Child and Adolescent Mental Health Service (CAMHS), registered psychologists or
psychiatrists, for paediatric patients with eating disorders will be accepted by the Nutrition Department.
NAHS Dietetic Guideline for the Management of Eating Disorders in paediatric patients Policy 01-11AH
May-11
Referrals must be accompanied by a detailed assessment and care plan. Referrals must contain patient
name, date of birth, anthropometric data and eating disorder symptoms.
The Nutrition Department will not arrange outpatient appointments until such time as the Department
receives a copy of the referral and the care plan.
General practitioners who wish to refer a paediatric patient with a suspected eating disorder may be
advised by the Nutrition Department to firstly refer the patient to CAMHS, registered psychologist or
psychiatrist for an assessment and the development of a care plan.
Paediatric patients and their parents are not able to refer themselves for outpatient paediatric nutrition
services.

(ii) Existing patients

Paediatric patients discharged from the LGH following treatment for an eating disorder may access NAHS
paediatric nutrition outpatient services if referred by MDT members in ward 4K. Referrals must be faxed
to the Nutrition Department on 6348 7478 using the Allied Health referral form.
Outpatient services will preferably be provided by the Dietitian/s currently working as part of the MDT
managing eating disorder patients admitted to 4K as this dietitian/s may have increased knowledge and
familiarity with patients’ MDT treatment care plan arrangements.
If Dietitian/s currently within the 4K rotation is/are not available, a detailed handover, including the
provision of the patient’s nutrition care plan, to the Dietitian working in the paediatric outpatient clinic
must be provided

Failure to attend outpatient appointments

Patients who fail to attend one confirmed paediatric outpatient appointment will be sent a letter advising
that they need to contact the Nutrition Department within 4 weeks to re-schedule the appointment.
Failure to reschedule the appointment within this timeframe may result in the patient being discharged from
the service.
Patients who fail to attend two paediatric outpatient appointments will be advised that they have been
discharged from the nutrition department and that they will need to obtain a new referral from an eligible
referral source. In order to verify that the affected patient is receiving regular care from medical and
mental health professionals, a copy of an assessment and intervention/treatment plan – dated within the
previous 6 months – must be provided with the new referral before an outpatient appointment will be
scheduled.
All Staff
Positions accountable for
a. compliance with the policy: all NAHS dietetic staff
b. monitoring and evaluation of the policy: Nutrition Manager
c. development and revision of the policy: all NAHS dietetic staff
Unit Manager or Department Heads
Positions accountable for
a. compliance with the policy: Nutrition Manager
b. monitoring and evaluation of the policy: Nutrition Manager
c. development and revision of the policy: Nutrition Manager

NAHS Dietetic Guideline for the Management of Eating Disorders in paediatric patients Policy 01-11AH
May-11
References:
The Maudsley Model of Family Therapy for Children & Adolescents with Anorexia Nervosa: Theory,
Clinical Practice and Empirical Support. Paul Rhodes, ANZJFT, Vol 24, No. 4, pp 191 -198, 2003.

Performance Indicators: Number of paediatric patients affected by eating disorders seen in both the
inpatient and outpatient settings.
Attendance by dietetic staff at multidisciplinary team meetings for
paediatric inpatients.
Number of outpatient occasions of service provided to these patients with
the target being no more than three occasions of service.
Manager Nutrition Department is responsible for monitoring the
performance indicators
Review Date: Annually verified for currency or as changes occur, and reviewed every 3
years via the Document Development Checklist and process.
Developed By: NAHS dietetic staff
Stakeholders: NAHS dietetic, paediatric medical staff, CAMHS staff

NAHS Dietetic Guideline for the Management of Eating Disorders in paediatric patients Policy 01-11AH
May-11