Sadly, the numbers of Children and Young People presenting with a picture of severe, restrictive intake has increased exponentially in the last 2 years. This is undoubtedly a consequence of the pandemic. Young people have had to tolerate a high degree of uncertainty, a lack of structure, a loss of normal support functions. They have been without many normal peer interactions. Some have been increasing exposed to emotionally damaging home environments.
In seeking ‘control’/containment/certainty, a small subgroup of young people have turned to managing their intake in a way which has become pathological. Many of these would not meet criteria for a “typical” Eating Disorder (anorexia nervosa). Rather than body dysmorphia and a fear of fatness, per se, they have become obsessional about the need regulate their bodies. Many have had unhelpful relationships with social media accounts promoting weight loss or dieting. A smaller subgroup speak of the “need” to be, or appear, unwell.
A clinical challenge for CAMHS and paediatrics has been the management of the physical health risks of these young people. Some become so compromised (bradycardia, hypotension, weakness) that they need inpatient care. We know from the evidence that specific “Eating Disorder” unit admissions tend to be very lengthy and involve being a long way from home. The evidence that such admissions are beneficial is poor. Most young people are best managed close to home, with short, planned admissions to paediatrics, supported by a close collaborative network of mental and physical health professionals.
Inevitably, some of these young people are so unwell that they may need feeding against their own wishes – via nasogastric tube. In a smaller number of cases, the resistance to this intervention may be so high as to necessitate clinical holding or even restraint, to protect the life of the child. Such an intervention is not entered into lightly. There are significant ethical and practical considerations to be made. Not least, what legal frameworks can and should be used to facilitate feeding.
Published today, a good paper by Sarah Fuller and colleagues sets out some of the challenges:
Most acute trusts are finding that their paediatric wards are increasingly having to manage these complex situations. All hospitals should have a lead for Young People’s Mental Health (as per NCEPOD and RCHCH guidance). There is a drive to skill up paediatric staff across the board.
In Summary: The pandemic has brought a wave of distress for many young people, some of whom require intensive and at times restrictive care for their recovery. We appear to be encountering a novel clinical presentation, in some. NHS England recognises the urgency to adapt clinical environments to attend to these often rather desperate young people.
It is hoped that the ‘resolution’ of the pandemic may help us return to pre-COVID levels of referrals, but many of us on the frontline are not so sure. The ripples of the pandemic will be felt for some time.