Anorexia Bulimia Paediatric

Key questions

  • New symptoms (e.g. syncope, weakness)
  • Recent weight loss
  • Daily caloric intake
  • Physical activity levels
  • Engagement with services and social supports
  • Other mental health diagnoses
  • Self-harm and suicidal ideation

Baseline investigations

  • Height and weight - paediatric BMI calculator (
  • Temperature
  • ECG
  • Lying/standing BP
  • FBC, U&E, Ca++, Mg++, PO4- (refeeding syndrome) ±HCG
  • If purging, consider VBG & CXR (oesophageal rupture)
50th centile BMI
9 16 16.4
10 16.4 16.9
11 16.9 17.5
12 17.4 18.1
13 18 18.8
14 18.7 19.4
15 19.3 20
16 20 20.4
17 20.5 20.8
18 21 21
19 21.5 21.5
20 22 21.7


Red flags

  • SUSS ≤2 (details below)
  • Postural drop
  • Bradycardia
  • Hypothermia
  • Electrolyte AbN
  • QTc > 450ms


  • Refer CAMHS
  • Also refer paediatrics if indicated by any red (High Risk) or amber (High concern) features below (Source: Junior Marsipan Guidelines 2015)
Clinical RED
High risk
Alert to high concern
Moderate risk
Low risk

1. %median BMI

<70% 70-80% 80-85% >85%

2. Recent Wt loss

≥1 kg/wk x2wks 0.5-0.99 kg/w x2wks ≤0.5 kg/w x2wks No wt loss in past 2wks

3. HR & rhythm

HR (awake) <40bpm a

Irregular rhythm

Tachycardia or inappropriate normal HR for degree of under-wt, ↓BP & ↑CRT (hypovolaemia)

HR (awake) 40-50bpm HR (awake) 50-60bpm HR (awake) >60bpm (NSR)

4. Resting BP

  SBP (sitting <0.4th centile (84-98mmHg)
DBP (sitting) <0.4th centile (35-40mmHg)
SBP (sitting) <2nd centile (88-105mmHg)
DBP (sitting) <2nd centile (40-45mmHg)
Normal sitting BP for age and gendera

Orthostatic Δ

Orthostatic ↓ in SBP ≥20mmHg
Orthostatic ↑ in HR of >30bpm
Orthostatic ↓ in SBP ≥15mmHg
Orthostatic ↑ in HR of 30bpm
Normal orthostatic changes but pre-syncopal Normal orthostatic cardiovascular changes


Hx of recurrent syncope Occasional syncope Pre-syncopal but normal orthostatic changes No syncope

5. ECG

QTc > 460ms M&F <15yrs
QTc >460ms F> 15yrs
QTc >450ms M>15yrs
Brady or tachyarrhythmia (excludes sinus brady):ECG evidence of biochem. abnormality
QTc >460ms M&F <15yrs
QTc >460ms F>15yrs
QTc >450ms M>15yrs
QTc 440-460ms M&F <15yrs
QTc 450-460 >15yrs
QTc 430-450ms M>15yrs
Taking meds known to prolong QTc interval or FHx ↑QTc or sensorineural deafness
QTc <440ms M&F <15yrs
QTc <450ms F > 15yrs
QTc <430ms M >15yrs

6. Hydration

Fluid refusal.
Severe dehydration (10%): ↓urine output, dry mouth, ↓skin turgor, sunken eyes, tachypnoea, tachycardiab
Severe fluid restriction.
Mod. dehydration (5-10%): ↓UO, dry mouth, normal skin turgor, mild tachypnoea, some tachycardiab, peripheral oedema
Fluid restriction.
Mild dehydration (<5%): dry mouth / not clinically dehydrated but concerns about risk of dehydration with negative fluid balance
Not clinically dehydrated

7. Temp

<35.5°C tympanic or 25°C axillary <36°C ≥36°C ≥36°C

8. Biochem

↓K, ↓PO4, ↓Na, ↓Ca, ↓alb, ↓glu ↓K, ↓PO4, ↓Na, ↓Ca None None

9. Disordered eating

Acute food refusal or est. intake 400-600kacl/day for 2-4 days Severe restriction (<50% of required intake) for 2-4 days, purging Moderate restriction, bingeing None

10. Engagement

Violence (parent or child) Poor insight Some insight, ambivalent Some insight & motivation

11. Activity / exercise

>2 hrs a day uncontrolled exercise (in context of malnutrition) >1 hr a day uncontrolled exercise (in context of malnutrition) <1 hr a day uncontrolled exercise (in context of malnutrition) No uncontrolled exercise

12. Mental Health

Self harm and suicidal ideation Self harm
Other mental health Dx

13. SUSS test
(Sit-Up, Squat-Stand)

Unable to sit up at all from lying flat(0)
Unable to stand up at all from squatting(0)
Unable to sit up from lying without using arms(1)
Unable to stand up at without using arms(1)
Unable to sit up from lying flat without noticeable difficulty (2)
Unable to stand up without noticeable difficulty(2)
No difficulty(3)

No difficulty
a. Patients with inappropriate normal/high HR for degree of underweight are at even higher risk (hypovolaemia). HR may also be ↑ purposefully by consuming excess caffeine or other drinks.
b. Or inappropriate normal HR in an underweight young person.

Content by Dr Jenny Miller, Dr Rory O'Brien, Dr Íomhar O' Sullivan 11/01/2021.