Definition, types and risk factors

Eating disorders are serious mental health conditions that are driven by an overevaluation of one’s body weight and body shape and characterised by abnormal eating patterns – either strict control or lack of control of eating (American Psychiatric Association (APA) 2013). There are various types of eating disorder (Box 1), one of which is anorexia nervosa. An individual with this condition has an intense fear of gaining weight and severely restricts their food intake, which often leads to severe malnutrition (APA 2013).

Research has suggested that in the UK the incidence of anorexia nervosa peaks at the age of 15 years in females and 16 years in males (Petkova et al 2019). Young people with this condition may require admission to a children’s ward for medical stabilisation and monitoring, notably to prevent refeeding syndrome. Refeeding syndrome is characterised by a sudden drop in electrolytes when the metabolism changes from a starved state to a fed state, which can have significant detrimental effects on the neurological and cardiovascular systems (Royal College of Psychiatrists (RCPsych) 2022).

Exactly what causes eating disorders is not known, but risk factors include having low self-esteem, being perfectionistic (Johnston et al 2018), being exposed to bullying (Lie et al 2019), having a family history of eating disorders (Bulik et al 2019) and being exposed to traumatic events such as a bereavement (Bakalar et al 2015). A clinical report on the interaction between obesity prevention and eating disorders in adolescents suggested that those who dieted were up to five times more likely to develop an eating disorder, and that those whose diet was considered extreme were 18 times more likely to develop an eating disorder, than those who did not diet (Golden et al 2016).

Since the start of the COVID-19 pandemic, the number of children and young people starting treatment for an eating disorder increased by almost two thirds (NHS England 2022). There appear to be many contributing factors to this increase, including lockdowns causing significant disruption to routines, for example because of school closures; food insecurity; social isolation; increased levels of anxiety; and exposure to public health messages promoting healthy eating and exercise (Branley-Bell and Talbot 2020).

Hospital admission

In young people with an eating disorder that causes weight loss, the aim of hospital admission is to re-establish regular eating to a level that promotes weight gain and medically stabilises the young person so that they can return home (Hudson and Chapman 2020). Referral to specialist inpatient mental health units is appropriate only in certain circumstances – for example, when intensive support in the community is ineffective or if the young person has co-morbidities such as obsessive-compulsive disorder or bipolar disorder.

Many people with an eating disorder who have developed malnutrition experience a deterioration in their mental and physical health – for example, increased anxiety, low mood and/or a fixation on food (RCPsych 2022). Research has suggested that young people do better when treated at home with their family supporting them (Gowers et al 2010, National Institute for Health and Care Excellence 2020), but some may require specialist inpatient mental health support, particularly if they present with self-harming behaviours or suicidal ideation.

Before the COVID-19 pandemic, there was already a limited number of beds available for young people with an eating disorder in specialist inpatient mental health units in the UK. During the pandemic, some units have had to reduce their capacity on account of social distancing measures. This lack of capacity means that many young people who need specialist mental health support have to stay on a children’s ward until a bed is available in a specialist inpatient mental health unit.

Furthermore, specialist inpatient mental health units are not equipped to manage the medical risks associated with severe malnutrition caused by an eating disorder. In such cases, it is the role of staff on children’s wards to ensure that the young person is medically stable before they can be transferred to a specialist inpatient mental health unit (RCPsych 2022).

Treatment without consent

The treatment for most of the markers of medical instability associated with malnutrition related to an eating disorder that restricts nutritional intake – which include bradycardia, hypotension, hypothermia, abnormal electrocardiograph and abnormal biochemistry – is nutrition (RCPsych 2022). That treatment is, however, in direct conflict with the psychological presentation of some people with anorexia nervosa, which is characterised by fear of food and/or weight gain (APA 2013).

Some young people admitted to a children’s ward can tolerate oral nutrition of a level that promotes weight gain and medical stabilisation. Others are unable to eat an amount of food that is sufficient to promote weight gain and medical stabilisation but can tolerate the intake of nutritional supplement drinks. For some, the fear of food and/or weight gain is so great that they require feeding via a nasogastric tube for a short period with their consent (RCPsych 2022). When a young person’s physical health is so compromised by malnutrition caused by an eating disorder that there is a risk of death, nasogastric tube feeding without their consent and under physical restraint may be required as a lifesaving intervention. That intervention is likely to be traumatic (Kodua et al 2020).

The decision to deliver nasogastric tube feeding to a young person without their consent requires multidisciplinary involvement and discussion with the young person, their family, child and adolescent mental health community eating disorder service staff and the paediatric team. The complex ethical and legal aspects of nasogastric tube feeding under restraint on children’s wards are beyond the scope of this article, which focuses on the practical aspects of the intervention. More information on ethical and legal aspects can be found in Fuller et al (2022).

Legal framework

In the UK, young people who need to receive nasogastric tube feeding without their consent have to be detained under the relevant mental health legislation, most commonly the Mental Health Act 1983 (Department of Health (DH) 2015), since this intervention cannot be provided based on parental consent only. Under section 63 of the Mental Health Act 1983, medical treatment for a mental disorder can be given to patients detained under the act without their consent if the treatment is by or under the direction of the approved clinician in charge (DH 2015).

The Mental Health Act 1983 requires adherence to five principles: least restrictive option and maximising independence; empowerment and involvement; respect and dignity; purpose and effectiveness; and efficiency and equity (DH 2015). These principles must guide all nursing care of patients detained under the act. However, nasogastric tube feeding without consent is likely to require the use of restraint, which contradicts the first principle of the act (least restrictive option and maximising independence). The act specifies that ‘any restrictions should be the minimum necessary to safely provide the care or treatment required having regard to whether the purpose for the restriction can be achieved in a way that is less restrictive of the person’s rights and freedom of action’ (DH 2015).

The following subsections offer practical guidance on nasogastric feeding in young people without their consent and under restraint. This guidance is largely based on the authors’ clinical experience and adheres to the five principles of the Mental Health Act 1983.

Administration

Nasogastric tube feeding has been shown to be safe and feasible in young people with an eating disorder who have consented to treatment (Hindley et al 2021). On children’s wards, nasogastric tube feeds, which may be used for a range of conditions, are commonly administered enterally either through pump feeding or gravity feeding. In young people who have not consented to treatment, administering nasogastric tube feeds in that manner can require the use of restraint several times a day for long periods at a time to ensure the required volume of feed is given.

To reduce the likely distress associated with a high number and long duration of feeds under restraint, children’s nurses can adapt their practice as follows (Falcoski et al 2020, Fuller and Philpot 2020):

Preparation

Nasogastric tube feeding under restraint must be undertaken in a treatment room or other suitably private space, not at the bedside, to preserve the young person’s dignity. Before bringing the young person into the room, the nurse should draw up all the feed into 50mL syringes and cover the syringes so that the young person does not see them upon entering the room. This may reduce their distress. The treatment couch needs to be placed in a position that will enable the nurse to administer the feed from behind, so that the young person is less likely to be able to see the feed being administered. Again, this may reduce their distress.

A specific time of day should be set for the intervention and communicated to the young person to help them manage their anxiety. Delivering the intervention at the set time of day should be considered a priority, since any delay could increase the young person’s anxiety and subsequently their distress during the intervention. Furthermore, it is important to discuss with the young person, at an appropriate time before the intervention, distraction techniques that could support them during the intervention. Some young people will feel calmer if they can look at their phone, listen to music or talk to another person during the intervention. Others will not want any distraction technique.

Communication

It is important that the young person should feel that they are listened to and understood, and that they have a degree of control over the situation. This can be achieved through sensitive communication, avoiding phrases that can be counterproductive and using language that is more likely to be perceived as supportive (Box 5).

Restraint

There are various levels of restraint. Restraint can range from one member of staff holding the young person’s hands to several members of staff holding the young person’s arms, legs and/or head, so that the young person cannot interrupt the insertion of the nasogastric tube or pull it out once it has been inserted.

The level of restraint should be negotiated with the young person before the intervention. Everyone involved in delivering the intervention should strive to use the least restrictive practice possible while ensuring the young person’s safety. If a feed has started and becomes unsafe because of the young person’s intensity of resistance, it must be stopped and the level of restraint re-evaluated. Only once the young person is safely restrained can the feed be restarted.

Only staff who are trained in the safe use of restraint techniques can participate in restraining patients. Participation in restraint by an untrained person could be regarded as assault, especially if the patient is injured in any way during the restraint. Hospitals ensure that there are staff who are trained in safe restraint, who often include security staff or porters. In extreme circumstances, if no appropriately trained healthcare professional is available to participate in restraining the young person, assistance from security staff or porters may be needed. Under no circumstances should parents be involved in restraining their child, since they are not trained and this would be a highly distressing situation.

After the intervention

To ensure that the young person retains the prescribed feed, used syringes must not be left unattended since there is a risk that the young person may attempt to use them to decant their feed (by attaching the syringe to the nasogastric tube and drawing out the feed they have just been given). The nurse may also want to restrict the young person’s access to the toilet or bathroom for one hour after the intervention to reduce the risk of the young person making themselves sick. In that case, the nurse will need to prompt the young person to use the toilet before the intervention. It can be helpful to offer the young person a post-feed distraction, such as spending time with family or the play therapy team, to assist in calming them and helping them to emerge from what is likely to be a state of high distress.

An incident report should be completed after each episode of nasogastric tube feeding under restraint. It needs to contain information about the nasogastric tube, a pH test result confirming that the feed has entered the stomach and not the lungs, which members of staff were involved in restraining the young person, what holds they used and how long the young person was restrained for. As explained earlier, medical treatment for a mental disorder can be given to detained patients without their consent under section 63 of the Mental Health Act 1983, but it is still advisable to document the intervention so that staff are protected in case of accusations of assault.

A staff debrief should be held after each episode of nasogastric tube feeding under restraint. It is important to acknowledge that the intervention can be distressing for the staff involved. Nurses who care for young people who need nasogastric tube feeding under restraint may require additional support, for example from occupational health.