Synopsis
Recognise restrictive, binge-purge and avoidant eating disorders throughout development, assess growth and all-domain MEED risk without a weight gate, provide family-inclusive specialist treatment, and manage medical instability, refeeding, consent and safeguarding safely.
- Young people can have anorexia nervosa, atypical anorexia, bulimia, binge-eating disorder, ARFID or another specified disorder at any body size and in any gender.
- Plot weight and height over time, assess puberty and use age- and sex-adjusted measures including percentage median BMI through age 18; one current BMI is not a severity assessment.
- Ask privately about restriction, fear and rules, bingeing, vomiting, laxatives, diuretics, exercise, water loading, supplements, insulin omission, body checking, sensory avoidance and choking or vomiting fears.
- ARFID is driven by sensory sensitivity, feared consequences or low interest rather than weight-shape concern, but its malnutrition and refeeding risks can be equally serious.
- MEED is an all-age, multi-domain clinical aid: one red or at least two amber findings should probably be considered high risk, while judgement remains essential.
- NICE says not to use a single BMI, weight or illness-duration threshold to decide referral, treatment or admission; suspected eating disorder warrants immediate specialist referral.
- Consider anorexia-nervosa-focused family therapy for children and young people, making clear that families are not blamed and giving the young person individual time.
- For bulimia in children and young people, offer bulimia-focused family therapy, with CBT-ED when family therapy is unacceptable, contraindicated or ineffective.
- Refeeding is life-preserving treatment delivered through a written specialist protocol with vitamins, phosphate, potassium and magnesium monitoring; excessive caution can itself prolong dangerous undernutrition.
Key red flags
MEED treats an awake heart rate below 40 beats/minute as red and warns that tachycardia or an apparently normal pulse in severe undernutrition may indicate infection or hypovolaemia.
For those under 18, percentage median BMI below 70% is a red range, but rapid loss, faltering growth and physiology can be dangerous well above it.
Potassium below 2.5 mmol/L, glucose below 3 mmol/L, falling phosphate, severe dehydration, significant ECG abnormality or marked hypothermia requires urgent medical escalation.
Multiple daily vomiting, laxative or diuretic misuse, water loading, insulin restriction, driven exercise or acute intake failure may create danger that weight does not reveal.
Suicidal intent, severe self-harm, abuse, coercive feeding or weight control, exploitation or a home unable to support essential nutrition requires same-day psychiatric and safeguarding planning.
Investigation priorities
Plot height, weight and developmental trajectory and calculate percentage median BMI through age eighteen.
Management branches
Eating behaviour, growth, purging, exercise, body concern or ARFID consequences suggest an eating disorder.
- Complete physical and psychiatric risk assessment, obtain indicated observations, glucose, bloods and ECG, and assess safeguarding and support.
- Refer immediately to an age-appropriate specialist eating-disorder service without waiting for low BMI or a screening threshold.
- Name who will monitor growth, observations, intake, bloods and deterioration while specialist assessment is pending.