Management of Eating Disorders in the Emergency Department

* Approved by CPG Committee; PIC endorsement pending

Key points

Children and adolescents with eating disorders (EDs) can appear well despite being medically unstable with cardiovascular complications, electrolyte imbalances and dehydration
Nutrition and hydration should only commence after initial investigations (blood glucose level and electrolytes) have been reviewed and a nutrition/hydration plan is discussed with the admitting team
There is a risk of refeeding syndrome when commencing nutrition
Children and adolescents with EDs can present with suicidal ideation, escalating ED compensatory behaviours or comorbid psychiatric disorders requiring urgent mental health assessment

Background

Eating disorders (EDs) are potentially life-threatening conditions. Anorexia nervosa (AN) has the highest mortality of any psychiatric disorder
Early recognition and intervention are important to prevent chronic impairment and assist with successful recovery
Medical complications (eg cardiovascular derangement, electrolyte imbalances, dehydration) are a consequence of starvation, bingeing, purging, and other associated behaviours
Avoidant/restrictive food intake disorder (ARFID) also has the potential to lead to medical instability. Its assessment is complex and specialist input should be sought, however criteria for admission are similar to other EDs

Assessment

History

Assessment approach depends on whether this is the child or adolescent's first presentation of suspected ED versus a known diagnosis of ED

First presentation and ED diagnosis is suspected

Helpful questions include (dedicated screening questionnaires under Additional Resources below):

Thoughts/cognitions around body image, weight and shape, fear of weight gain
Dietary history eg food and fluid type and quantity, intake over a typical day
Eating behaviours
- Restricting meal portions or specific foods and food groups, skipping meals
- Mealtime behaviours and rituals, emotional dysregulation with meals
- Calorie counting
Discord with family over intake
Binge eating
Exercise frequency, duration, type, intensity and motivation
Other weight control measures eg laxatives, diuretics, purging
Participation in activities with high risk for ED eg high-level sport

Known diagnosis of ED

Review of food and fluid intake
Review of exercise and other weight control measures as above

All patients

Reported current weight, pre-morbid and highest weight, and rapidity of weight loss
Fainting, dizziness, palpitations, cold intolerance, constipation and abdominal symptoms
- Menstrual history including menarche, amenorrhoea, and regularity of cycles
Mood, risk of suicide and self-harm. See Mental State Examination
Psychosocial assessment including HEEADSSS screen. See Engaging with and assessing the adolescent patient
- Common co-morbid mental health conditions: Autism spectrum disorder, anxiety, depression, PTSD, OCD
- Medications eg stimulants, insulin (non-compliance)

Examination

Weight, height and body mass index (BMI)
Temperature
Postural HR and BP. Ensure measurements are 2-3 minute apart, lying to standing
Signs of undernutrition: poor circulation, pallor, loss of muscle mass and subcutaneous fat, lanugo (fine hair covering the body)
Signs of self-purging: Dental enamel erosion, Russell's sign (abrasions/calluses on back of interphalangeal and metacarpophalangeal joints from purging), enlarged salivary glands
Acrocyanosis
Pressure sores, dry skin
Delayed pubertal development
Mood and mental state

Management

Investigations

Blood tests
Glucose, venous blood gas, UEC, Ca, Mg, PO₄, FBE, LFTs, ketones
If new diagnosis: ESR, thyroid function, coeliac screen
Consider nutritional testing during admission (if not done in the last 3 months) including ferritin, vitamin B12, red cell folate, vitamin D and zinc (see Micronutrient deficiency)
Urinalysis (if concern for T1DM, specific gravity, ketosis), βhCG if amenorrhoeic
12-lead ECG
If secondary amenorrhoea: consider FSH, LH, sensitive oestradiol/serum testosterone in discussion with admitting team

Admission

The Risk Stratification table below allows for consideration of all relevant medical and psychosocial criteria to determine risk and need for admission, and provides flexibility depending on individual location and circumstance

Admission should be strongly considered for children or adolescents who demonstrate medical instability, ie any "Red flag" features or multiple "Amber flag" features, as shown in the Risk Stratification table below

Discuss with the Paediatric or Adolescent Medicine on-call clinician:

For navigation to the appropriate inpatient unit eg local Paediatric inpatient unit or specialized Adolescent or Eating Disorders inpatient unit if available
If you are unclear whether the child/adolescent adequately meets criteria for admission

Risk Stratification for Admission

	Consider admission Discuss with on-call consultant	Concern Discuss with on-call consultant	Moderate risk Weekly review
Signs of Medical Instability
HR Awake and Postural change	<50 bpm Increase in postural HR of >50 bpm	50-60 bpm Increase in postural HR of >20 bpm	>60 bpm Normal postural change
BP normal and postural	SBP <80 or postural SBP drop of >20 mmHg	SBP <90 or postural SBP drop of>15 mmHg	Normal resting SBP for age and gender and postural SBP drop of <15 mmHg
ECG	QTc >450 msec or other significant ECG abnormality
Biochemistry	Significant electrolyte disturbance or ketosis Hypophosphataemia ( <0.9 mmol/L) Hypokalaemia ( <3.0 mmol/L) Hypoalbuminaemia Hypomagnesaemia Hypoglycaemia ( <3.0 mmol/L) Hyponatraemia ( <130 mmol/L) Hypocalcaemia Transaminases >3x normal
Temperature	<35.5°C	<36.0°C	>36.0°C
Syncope	Recurrent	Occasional	None or pre-syncope
Hydration	Fluid refusal >48 hours or severe dehydration (>10%)	Severe fluid restriction or moderate dehydration (5-9%)	Minimal fluid restriction or no more than mild dehydration ( <5%)
Haematology		Low white cell count Hb <100 g/L
Weight loss
Weight Loss	>1 kg/week OR >15% in 3-6 months	0.5 to 1 kg/week	<0.5 kg/week or fluctuating weight
% of Median BMI^1-3 See Median BMI tables for calculated values	<70%	70-80%	>80%
Compensatory behaviours
Disordered Eating	Complete food refusal for 48 hours	Difficult to control ED compensatory behaviours - prolonged fasting, uncontrolled purging or exercise
Engagement with management	Physical struggles with carers over meal plans or reduction of exercise Severe family stress/strain
Purging behaviours	Oesophageal tears and/or haematemesis	Multiple daily episodes of vomiting and/or laxative abuse	Regular (>3/week) vomiting and/or laxative abuse
Mental Health Concerns
Self-harm and suicidality	Self-poisoning/overdose Suicidal ideas with moderate to high risk of completed suicide (active intent and plan)	Cutting or similar behaviours Suicidal ideas with low risk of completed suicide

BMI = weight (kg) ÷ height (m)²
Median BMI for age and gender = BMI at 50^th centile for age and gender
Percentage (%) of Median BMI for age and gender = (Current BMI ÷ Median BMI for age and gender) x 100. See Median BMI tables for calculated values

Nutrition and hydration

Nutritional and fluid resuscitation/re-introduction incurs medical risks including:

Refeeding syndrome: potentially fatal shifts in fluids and electrolytes that may occur in undernourished children/adolescents being re-fed. The hallmark biochemical feature of refeeding syndrome is hypophosphataemia
Fluid overload and cardiac compromise with significant oral or IV fluid administration

Nutrition and hydration should only commence after initial investigations have been reviewed and a nutrition/hydration plan is discussed with the admitting team

The agreed plan should commence as soon as possible, ideally in the emergency department
If feeding/nutrition commences in the emergency department, consider initial supplements prior to starting:
- Thiamine 100 mg orally
- Phosphate 500 mg (elemental) orally

Cardiac monitoring

Consider ongoing cardiac monitoring after discussion with the admitting consultant for

Severe electrolyte disturbance eg K <2.5 mmol/L
HR <45 bpm
HR <40 bpm asleep

Medically stable and medical admission not required

Does the child or adolescent require mental health assessment? See below, and Mental State Examination
If urgent mental health assessment is not required
- New diagnosis of ED: discuss with the on-call consultant regarding outpatient management
- Known ED diagnosis: refer to the appropriate local mental health/ED service or contact child/adolescent's known ED clinician

Mental health assessment

Children and adolescents with EDs can present with suicidal ideation, escalating ED compensatory behaviours or comorbid psychiatric disorders
Urgent mental health team assessment may be required. If there are concerns about mental health, discuss with local mental health team

Consider consultation with local paediatric (or adolescent) team when

The child or adolescent is medically unstable (as above) or requires admission
First presentation of ED
To discuss appropriate outpatient follow up after discharge from the emergency department

Consider transfer when

For medically unstable children/adolescents who require escalation of care beyond capacity/comfort of the local team/facility

For emergency advice and paediatric ICU transfers, call Retrieval Services

Consider discharge when

Medically stable
Mental health assessment completed
Appropriate medical and/or mental health follow up arranged

State-based units and additional resources

See also Engaging with and assessing the adolescent patient: Referral pathways and services

Eating Disorders Victoria: Support, information, community education and advocacy for people with eating disorders and their families in Victoria

Child and Adolescent Mental Health Services (CAMHS): Victorian government mental health services are region-based

The Victorian Centre of Excellence in Eating Disorders (CEED): Victorian program providing clinical support for health professionals and services

Western Australia

Perth Children's Hospital Eating Disorders Service

WA Children and Adolescent Health Eating Disorders Guideline

Centre for Clinical Intervention (CCI) Eating Disorders Resources for Clinicians

Child and Adolescent Health Service | CAHS - Mental Health (CAMHS)

WA Eating Disorders Outreach and Consultation Service: for young people >16 years of age

Screening questionnaires

SCOFF screening questionnaire: 5-question screening tool to clarify suspicion for the presence of an ED

CEED Eating Disorder Screening Interview

Eating Disorder Examination Questionnaire (EDE-Q)

National resources and resources for families

Inside Out (Institute for Eating Disorders): Australia's national institute for research, translation and clinical excellence in eating disorders

Butterfly Foundation: national charity for all Australians impacted by eating disorders and body image issues and for families, friends and communities who support them

National Eating Disorders Collaboration

Reference List

Royal College of Psychiatrists. Medical Emergencies in Eating Disorders: Guidance on Recognition and Management (May 2022). https://www.rcpsych.ac.uk/docs/default-source/improving-care/better-mh-policy/college-reports/college-report-cr233-medical-emergencies-in-eating-disorders-(meed)-guidance.pdf?sfvrsn=2d327483_59 (viewed 8 March 2025).
Perth Children's Hospital. Eating Disorders. https://pch.health.wa.gov.au/For-health-professionals/Referrals-to-PCH/Prereferral-guidelines/Eating-Disorders. (viewed 8 March 2025)

Last updated August 2025

The Royal Children's Hospital Melbourne

Clinical Practice Guidelines