Paediatricians warn parents to be alert to signs of eating disorders over holidays

Paediatricians have seen a huge rise in cases of anorexia nervosa and other food restriction disorders in this age group, with some reporting a doubling, tripling or even quadrupling of cases compared with the same period last year.

The Royal College of Paediatrics and Child Health (RCPCH) is alerting parents and guardians to look out for signs of eating disorders in children and young people over the holiday period. 

The College spoke to paediatricians from around the country working in the field (see below). All had seen an increase in cases in the last year, and all put this down to the effects of the pandemic on young people’s lives.

Dr Simon Chapman, Consultant Paediatrician, (King’s College Hospital and South London and the Maudsley):

I’ve worked in eating disorders for 10 years and I have never known us to be so busy. Referrals since March have tripled.

Dr Nancy Bostock, Consultant Paediatrician, The Croft Child and Family Unit, Cambridge:

In our Tier 4 under 13’s mental health inpatient unit we have seen a three to fourfold increase in children referred to our service with eating disorders, and they are just the tip of the iceberg.

A number of factors are thought to have contributed to increased stress, deterioration in young people’s mental health and an intense focus for some on eating and exercise during the pandemic. These include: isolation from peers during school closures, exam cancellations, loss of motivating extra-curricular activities such as sports, dance/drama/youth clubs; an increased use of social media with young people concentrating on unrealistic ideas of body image; being forced to quarantine (a particular problem for many students newly arrived at university); worries about families’ economic problems; illness or death of loved ones, and fears about contracting the virus.

Dr Karen Street, a consultant paediatrician at the Royal Devon and Exeter Hospital in Exeter and Officer for Child Mental Health at the RCPCH, said:

We are extremely concerned about many children and teenagers’ wellbeing because of the pandemic. Many of them are just not coping.  Eating disorders are often related to a need for control – something many young people feel they have lost during the pandemic. Many have described needing a focus and goals which, in the absence of anything else, has for some centred around eating and exercise.

Reduced access to services and face-to-face consultations during the pandemic are thought to have caused an increase in cases where the young person has become severely ill by the time they were seen. Paediatricians reported seeing children and teenagers being brought into emergency departments in need of immediate admission to hospital for physical stabilisation and re-feeding.  Waiting lists for eating disorder treatment in mental health services are in many cases becoming completely overwhelmed and specialist inpatient beds are increasingly scarce.

Teachers and university staff often flag concerns about a young person’s weight loss or eating habits. The closure of schools and university classes and move to online lessons has inevitably made this more difficult, coupled with the fact that teachers are already under enormous pressures because of trying to reorganise lessons, manage infection control and cope with reduced staff because of illness. University counselling services are also under extreme pressure.

The College has taken the step of issuing an alert to parents to watch for signs of eating disorders over the holiday season in order to catch problems as early as possible. Christmas can be a stressful time for those struggling with issues around food. Many families will not have seen young people home from university or school for some weeks and may notice marked changes in eating behaviour, exercise patterns and weight. At the same time, new year is when there is often a lot of talk of dieting and exercise, with some people embarking on new year’s resolutions involving crash dieting or exercising more than is healthy.

Dr Karen Street commented:

We know that the earlier eating disorders are spotted (see below for warning signs), the better the chance that a young person can be successfully treated. Eating disorders begin with often quite small changes such as refusing to eat foods that were previously enjoyed. If you’ve noticed a difference in the way your child or teenager approaches food and exercise and it concerns you, talk to them about what’s normal and what is not – often those with eating disorders will try to convince you all is OK but trust your instincts. Seek advice from your GP and from helplines* and if you’re still concerned, contact local eating disorder team.

“Exercise is really important for young people. But too much exercise coupled with reduced eating in a young person who is a healthy weight really needs to be watched as it can quickly become a very serious problem, one with a high mortality rate.

Help and support

BEAT eating disorders charity has a lot of useful information on their website and their helpline is open over the festive period.

What our members are seeing

Dr Karen Street (Royal College of Paediatrics and Child Health Officer for Mental Health, Royal Devon & Exeter Trust): 

“We have reports from all over the country of increased referrals for eating disorders. There are 2 typical groups. The first is high-achieving young girls who are really driven, with a carefully mapped future that has been taken away, along with extracurriculars (if I had £1 for every time I heard a story of crashed weight beginning with ‘at the start of lockdown, when GCSEs were cancelled…’). 

“The second group includes those with personality disorders and problems with emotional regulation (which tends to be more girls than boys). They just don’t know how to cope and have stopped eating entirely, leading to several urgent admission that, in turn, often lead to formal diagnoses of personality disorders.  

“There is also a small group of boys with muscle-orientated body image disorder, who are broadly similar to the high-performing girls, but they don’t come to hospital as much. 

“Young people are also reaching us much sicker than they were before, and this is almost certainly because they are having less face-to-face interaction with GPs. GPs can't see, or weigh, them during a telephone consultation, so by the time they arrive to us they are in worse shape. 

“When lockdown disappears, the problem will remain. The pandemic has potentially created a large number of eating disorders that will take 2-3 years to recover.” 

Dr Simon Chapman (Consultant Paediatrician, King’s College Hospital and South London and the Maudsley): 

“I’ve worked in eating disorders for 10 years and I have never known us to be so busy. Referrals since March have tripled. It has been made harder during the pandemic because assessments and treatment have to be done through a screen.  

“Sometimes, though, that just doesn’t work, and we have had to bring people up to the hospital. When families do come it has often been going on for several months, and of course the young people are very ill by then. I would say to any parent or teacher, if they notice anything different about their young person and are worried, they may be developing an eating disorder, talk early on to the GP about their concerns or reach out to their local eating disorders service for advice.” 

Dr Nancy Bostock (Consultant Paediatrician, The Croft Child and Family Unit, Cambridge):

“In our tier 4 under 13’s mental health inpatient unit we have seen a three-to-four-fold increase in children referred to our service with eating disorders, and they are just the tip of the iceberg. Anecdotally, I have heard that another community eating disorder service in this region has had a fourfold increase in referrals.  The acuity of the referrals has also increased – with a higher proportion of children requiring naso-gastric feeds, which puts a greater pressure on paediatric inpatient units, and mental health inpatient units. 

“In the under 13’s population, the clinical picture is more likely to be an ARFID or emotionally driven food refusal picture rather than a classically anorexia nervosa, which I think relates to the need for children to feel in control at an extremely unsettled time.” 

Dr Luci Etheridge, Consultant General Paediatrics and Young People’s Health, Consultant Paediatrician CAMHS Community Eating Disorders, St George’s Hospital, London:

“Our referrals to the SW London CYP community eating disorders service have increased by 250% compared with 2019, with the bulk of this since September 2020. We currently have over 30 children on a waiting list for assessment, when previously we have always managed to meet the national access and waiting times standard of all referrals being assessed within 4 weeks. Many of these children are deteriorating on the waiting list. 

“The difficulties caused by lockdown and the loss of school are a universal part of the narrative in new presentations. It is common for young people to talk about anxiety increasing with the loss of school and worry about inactivity, often leading to a change in eating and exercise, which has played a part in precipitating an eating disorder. There are other factors mentioned, like loss of control, change in family relationships, sense of hopelessness for the future.”   

Dr Jonathan Rabbs (Consultant Paediatrician, Sussex): 

“Our ED service was commissioned for 11 new referrals a month. For the past 2 months we’ve had about 100 a month. The evidence for an increase in presentation of all acute mental health admissions to paediatric wards is incontrovertible, particularly food restriction. Possibly half the cases are not eating disorders per se but varying forms of hunger strike or food restricting due to anxiety, trauma, Autism Spectrum Conditions or social issues and care seeking behaviour. 

“I think we need to send a loud message to parents and schools to educate and support children and young people around anxiety, particularly girls, on the dangers of diet manipulation. There is often a pattern of thinking ‘I’m unhappy (looks at Instagram or whatever) it must be because I’m fat…’. They get control over something in their lives ie diet and feel better and then go ‘I feel better, must be because I’m thin, must get thinner…’.”

Dr Anna Kyle, Consultant Paediatrician, Somerset Partnership NHS Foundation Trust: 

“We’ve seen a 23% rise in referrals. In addition to anorexia nervosa, there are also lots of cases of restrictive eating that are difficult to capture based on discharge summaries and coding. For instance, people in for self-harm or suicidal ideation may turn out to have an eating disorder. It feels like around a 50% increase in hospital numbers.  

“There are two groups. 1) Those who have never seen a GP, CAMHS, or had a diagnosis, who are coming straight to us with really low weight. 2) The group who already had a diagnosis who have struggled with isolation and having to look at themselves in the screen of a video call (which might explain why they seem to hate remote services). 

“Disordered eating patterns is one way that some young people display their distress. When you’re low in mood, worried, or anxious, you feel nauseous and don’t want to eat. Some forms of disordered eating patterns can therefore be a sign of emotional upset. Disordered eating is a very different kettle of fish from eating disorders such as anorexia, though, which we know are multifactorial. 

“We have also seen a rise in functional disorders, such as rumination syndrome (with vomiting after eating) for instance, which have needed prolonged periods of support with nasogastric tube feeding. 

“There's an issue with Tier 4 beds. This was an issue before lockdown. 

“In general, separate cubicle beds are occupied by those with mental health needs. We like to be able to nurse them in their own space rather than an open bay. However, with limited single cubicle rooms, this causes competition with other patients that may also require them, such as those that are immunocompromised (cancer patients and un-immunised babies), so this also really impacts on the rest of the childhood population.” 

Dr Louise Phillips, Consultant Paediatrician, Glan Clwyd Hospital, Bangor, Wales:

“We developed a service for North Wales using the Maudsley Model for treatment of anorexia nervosa. Our 3 area CAMHS teams across North Wales each have an eating disorder lead who sends referrals straight to us. Our initial assessments are multi-disciplinary and comprehensive, including full physical assessment and take most of the day (09:00-14:30). They finish with a clear formulation and plan for the young person and their family.  

“Part of the plan involves removing apps from phones (things like calorie counters that can become obsessions). Technology, in general, may account for part of the trend, in that screen time is much higher under lockdown, and young people have far less to focus on. Physical exercise has also been encouraged and for some this will have become very obsessive and driven. 

“During COVID, I made the case that anorexia services were essential, due to the high risk these young people carry. We didn’t meet any resistance and have been operating throughout the pandemic.  

“We have a one-week target for urgent cases and a 4-week target for routine cases. Now, because of the rise in cases, we’re struggling to see urgent cases within 4 and some may have to wait 6 weeks. The number of referrals in the last 3 months has doubled.”   

Dr Joy Olver, Consultant Psychiatrist and North of Scotland CAMHS Tier 4 Network Consultant Psychiatrist, Young People's Unit:

“I am an inpatient consultant child and adolescent psychiatrist covering the North of Scotland.  We are hearing reports of marked increases in presentations of children with eating disorders - doubling or even tripling of eating disorders referrals in children to outpatient CAMHS in different health boards in Scotland.   

“I do not have further data on this to hand, just the reports from teams in the community. However, in the inpatient unit here (only 12 beds) there are unusually high levels of young people needing nasogastric feeding and support with eating due to eating disorders - 10 out of the 12 are needing meal support currently, which I am told is unprecedentedly high.”  

Dr Edwin Osakwe (Consultant Paediatrician, Oxford University Hospitals): 

“Our service is currently overwhelmed with new cases. New referrals Apr-Oct to our service increased by 57% compared to last year. Comparing December 2020 to December 2019, our overall caseload has increased by 57%. From April 20 to October 20, the number of cases referred to acute medical units for assessment or admission increased by 73% compared to same period last year. This suggests that we are not only seeing increased number of cases, but we are seeing patients that are more physically unwell (Apr-Oct).” 

Dr Penny Mancais (Consultant Paediatrician, Dorset County Hospital): 

“We’ve seen a surge of eating disorders in children at Dorset County Hospital. Four are currently inpatients. We normally have about one a year.  We have also had a few referrals for children who think they are being poisoned by their food, possibly linked to fears around COVID.” 

Dr Elizabeth Allison, Lead Consultant Paediatrician for eating disorders at Sheffield Children’s Hospital (medical lead in the region for the community eating disorders service): 

“We’ve seen around twice the number of referrals for medical outpatient reviews and around twice the numbers of inpatient medical admissions for patients with Anorexia Nervosa in 2020 compared to 2019 and these numbers appear to be continuing to rise even further since September.  The lockdown in the COVID-19 pandemic has created a fertile ground in which eating disorders can flourish. This is maybe due to the confinement away from young people's normal social and educational structure and also perhaps due to the increased exposure to social media influences. We are concerned that we may continue to see this trend continue over the next year or more."