refeeding

She was a little blonde waif with tired, pale blue eyes. Her England football jersey (with "Age 5" on the label) hung off her like a baggy nightdress. I've met anorexics before, but never one as young as *Jamie. She was nearly 9 and weighed 18 kilograms. The story was (and anorexics never tell the truth - it is part of the disorder) that she'd been at a talk on healthy eating at school, and had started cutting out crisps and cakes from her diet. One thing led to another, and eventually all she would eat was dry toast and a few sips of water. In the last few weeks she had become moody and had started sleeping in the afternoons. She'd been admitted into hospital to receive nasogastric feeds. My task as the night doctor was to do regular blood tests to check her phosphate, magnesium and calcium levels. These can become deranged when someone who has been starving for some time first receives nutrition - the refeeding syndrome.

It was a bit like taking blood from a very little old person. Her skin was dry and flaky, the veins knobbly and very mobile within her wrinkly arms. Her pulse was slow, at about 45/min and her blood pressure extremely low. The blood test results showed she was going into kidney failure, most likely from being so dehydrated. She hadn't had a wee for 36 hours. I dithered for ages about starting intravenous fluids - I didn't want her to be attached to too many lines for a prolonged period, but I also worried about giving her the fluid all at once (as a 'bolus') because of the risk of heart failure. I eventually opted for the latter, under close observation. It turned out to be the right decision.

Over the next few nights, her feeds were increased, and the frequency of blood tests decreased. She perked up dramatically, and on the fourth morning, sat up and smiled at me. She's got a long way to go, though. I'd thought that childhood anorexics had a better prognosis (in adults about 50% never recover and of these just under half die), but I've looked it up and it seems under-11s are significantly worse off.