Paediatric Review Letter

Clinician Specialty: Psychotherapist **"Our Ref:"** PR2024-1101-JG Clinic Letter 01/11/2024 01/11/2024 Miss Jane Green 14 Rose Lane Bristol BS1 1AB Sender's details Bristol Royal Hospital for Children Child and Adolescent Mental Health Services (CAMHS) Eating Disorders Team Upper Maudlin Street Bristol BS2 8BJ Telephone: 0117 923 0000 Department email: camhs.ed@bristolchildrens.nhs.uk **Re: Jane Green, 15/03/2009, NHS number: 123 456 7890** Dear Jane Green **Diagnosis:** Anorexia Nervosa, F50.0. Jane meets the criteria for Anorexia Nervosa, restrictive type, due to significantly low body weight, intense fear of gaining weight despite being underweight, and a disturbance in the way she experiences her body weight or shape. She has been restricting food intake consistently for the past six months, leading to significant weight loss. Comorbid diagnoses: * Generalised Anxiety Disorder (GAD) * Low mood Differential diagnosis: Atypical Anorexia Nervosa was considered given her presentation, but her current weight is below the expected minimum for her age and height, confirming typical Anorexia Nervosa. **Plan agreed at the review:** 01/11/2024 Who was present in discussion: * Jane Green (patient) * Mrs. Sarah Green (mother) * Dr. Eleanor Vance (Psychotherapist) * Dr. Liam O'Connell (Paediatrician) Brief one-line summary and overview plan without detail: Continued multidisciplinary support focusing on nutritional rehabilitation, psychological intervention, and medical monitoring to address the physical and psychological aspects of Jane's Anorexia Nervosa. Action points for specific individuals with direct actions required: * Action For Jane: Continue to follow the meal plan as discussed and attend all scheduled appointments. * Action For Mrs. Green: Ensure Jane adheres to the meal plan and medication regimen. Provide regular updates to the team. * Action For Dr. Vance: Continue weekly psychotherapy sessions focusing on cognitive restructuring and exposure to feared foods. * Action For Dr. O'Connell: Review blood results and physical observations weekly, adjusting medical management as needed. **Medical risks of low weight for height and unhealthy weight loss:** **Over time, being low weight for height can lead to numerous serious health consequences, rapid unhealthy weight loss can also lead to serious medical complications:** * Cardiac complications: Bradycardia, hypotension, and potential for arrhythmias. * Electrolyte imbalances: Particularly hypokalaemia, which can lead to cardiac dysfunction. * Osteoporosis: Reduced bone mineral density increasing fracture risk. * Renal impairment: Due to dehydration and electrolyte disturbances. * Gastrointestinal issues: Constipation, delayed gastric emptying. * Amenorrhoea: Cessation of menstrual periods, impacting bone health and fertility. **Bloods:** * **Electrolytes (28/10/2024):** Sodium 138 mmol/L (normal), Potassium 3.1 mmol/L (Low – **Implication: Increased risk of cardiac arrhythmias. Requires close monitoring and supplementation.**), Chloride 102 mmol/L (normal). * **Liver Function Tests (28/10/2024):** ALT 25 U/L (normal), AST 20 U/L (normal). * **Full Blood Count (28/10/2024):** Haemoglobin 12.8 g/dL (normal), White Cell Count 4.5 x 10^9/L (normal). * **Glucose (28/10/2024):** 4.8 mmol/L (normal). **Interventions:** * **Nutritional Support:** Fortified meal plan implemented (outcome: some initial resistance, but Jane is now consuming approximately 75% of target intake, implication: continued encouragement and monitoring of intake is crucial). * **Family-Based Treatment (FBT):** Ongoing weekly sessions with family (outcome: improved parental confidence in managing meals at home, implication: continued reinforcement of parental role in refeeding). * **Individual Psychotherapy:** Focus on body image and distress tolerance (outcome: Jane is beginning to challenge some distorted thoughts, implication: requires sustained therapeutic engagement to consolidate gains). **Medications and Nutritional supplements:** * Multivitamin and mineral supplement (once daily). * Potassium Chloride 8mmol (twice daily, adjusted based on blood results). Detailed summary of changes to medication and treatment plan over precise timeline detailing who will follow up and when, what to do in various possible outcomes, and how change will be assessed at next review: Jane's potassium supplement was initiated two weeks ago following a review of her blood tests which showed hypokalaemia. Dr. O'Connell will review her potassium levels weekly via blood tests until stable. If potassium levels remain low despite current dosing, Dr. O'Connell will consider increasing the dose or changing the formulation. If levels normalise, the dose will be maintained, and then reviewed at her next general paediatric appointment in four weeks' time. Dr. Vance will monitor Jane's adherence and any psychological impact of medication changes during weekly therapy sessions. The effectiveness of this change will be assessed by normalisation of blood potassium levels and absence of related physical symptoms at the next review. Recommended medical interventions: * ECG monitoring if potassium levels remain significantly low. * Bone density scan if amenorrhoea persists for over 6 months post-refeeding. Age: 15 years and 7 months Height: 1.62 metres (10th percentile) Mid parental centiles: Jane's height is currently below her mid-parental centile range, indicating potential stunting due to chronic undernutrition. Weight and BMI centiles and percentiles objectively reported: Weight: 38 kg (below 0.4th percentile), BMI: 14.5 kg/m^2 (below 0.4th percentile). Median percentage weight for height reported with impact/context included: 75% of median weight for height. This significant deficit indicates severe malnutrition and is directly contributing to her physical health risks. **Physiology:** * **Heart Rate:** 48 bpm (MEED score: 2 – **High risk**) * **Blood Pressure:** 90/60 mmHg (MEED score: 1 – **Moderate risk**) * **Temperature:** 36.0 °C (MEED score: 1 – **Moderate risk**) * **Capillary Refill Time:** 3 seconds (MEED score: 1 – **Moderate risk**) * **Oxygen Saturation:** 98% on room air (normal) **Discussion** During our review, you expressed ongoing anxieties regarding food intake and body image. We understand that increasing your nutritional intake feels challenging, and it's important to acknowledge the bravery you show each day in working towards your recovery. Your mother continues to provide excellent support in managing meals at home, and we commend her dedication. Your physical health remains a primary concern, particularly your low heart rate and potassium levels, which require vigilant monitoring. We discussed the specific risks associated with being underweight, including the potential for serious cardiac complications, and it is crucial that we continue to address these with a focus on safe refeeding. We also explored your feelings around your current body shape and the internal struggles you face. It's a complex journey, and your commitment to therapy is a vital step in regaining both your physical and psychological health. **Impression:** Our clinical impression is that you are continuing to struggle with severe Anorexia Nervosa, restrictive type, significantly impacting your physical and psychological well-being. Your current underweight status and associated physiological instability underscore the urgency of your treatment. The fear of weight gain and distorted body image perceptions are powerful maintaining factors, which we are addressing in therapy. We understand that this condition has a profound impact on your daily life and family, and we are committed to supporting you through this challenging period to achieve full recovery. **Plan:** Your current MEED rating is 5, indicating high physical risk due to bradycardia, hypotension, hypothermia, and low potassium. Therefore, continued close medical and psychological monitoring is paramount. Our plan is to continue with the established multidisciplinary approach, focusing on gradual nutritional rehabilitation and intensive psychological intervention. * **Increase Nutritional Intake:** You will continue to follow the structured meal plan provided, with a focus on meeting your caloric targets. Your mother will continue to supervise meals to ensure adherence. * **Psychotherapy:** Weekly individual psychotherapy sessions with Dr. Vance will continue, focusing on challenging your eating disorder thoughts, developing coping strategies, and improving body image. We will also incorporate family therapy to support your parents in their vital role. * **Medical Monitoring:** Dr. O'Connell will review your physical observations and blood tests, particularly your potassium levels, weekly. **It is crucial that you attend all medical appointments, as missed appointments could have serious health implications.** Any significant changes in your physical health, such as dizziness, fainting, or chest pain, must be reported immediately to the team. * **Medication Review:** Your potassium supplementation will be continued as prescribed by Dr. O'Connell, with regular blood tests to monitor effectiveness. * **Support:** We encourage you to utilise the support available through your school and any peer support networks that you find helpful. **Next review:** 08/11/2024, with Jane, Mrs. Green, Dr. Vance, and Dr. O'Connell. We agreed the plan as at the top of the letter. Yours sincerely, **_electronically checked and signed_** **_(Delegated signatory for Dr. Amelia Henderson)_** Signed By Dr. Eleanor Vance Dr. Amelia Henderson Consultant Child and Adolescent Psychiatrist Bristol Royal Hospital for Children Child and Adolescent Mental Health Services (CAMHS) Eating Disorders Team CC Copies to: * Dr. Robert Davies (GP) * Dr. Liam O'Connell (Paediatrician) * Ms. Chloe Adams (Dietitian) * Mrs. Sarah Green (Mother)