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 (https://www.cdc.gov/.....)
- Temperature
- ECG
- Lying/standing BP
- FBC, U&E, Ca++, Mg++, PO4- (refeeding syndrome) ±HCG
- If purging, consider VBG & CXR (oesophageal rupture)
| Age (yrs) |
♂ | ♀ |
|---|---|---|
| 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 |
SUSS
Red flags
- SUSS ≤2 (details below)
- Postural drop
- Bradycardia
- Hypothermia
- Electrolyte AbN
- QTc > 450ms
Disposition
- 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 |
AMBER Alert to high concern |
GREEN Moderate risk |
BLUE 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 |
Syncope |
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 plus 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 plus 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 |
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13. SUSS test |
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. |
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