Inpatient Management of Adolescents with Eating Disorders: What to Expect When a Patient Requires Hospitalization for Medical Stabilization

AUTHORS:

Marissa Feldman, PhD, ABPP¹; Sydney Ward, PsyD²; D. Paul Robinson, MD, FAAP^3,4
1,2Johns Hopkins All Children’s Hospital, Johns Hopkins University
³Tallahassee Memorial Healthcare Family Medicine Residency
⁴Florida State University College of Medicine

REVIEW ARTICLE | PUBLISHED SUMMER 2025 | Volume 45, Issue 3

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Abstract

Eating disorders are complex, disabling, and deadly, as they impact all aspects of functioning.¹ Medical complications related to dietary restriction or weight loss are significant, as eating disorders can affect every organ system.² Anorexia nervosa is one of two mental illnesses that carry the highest all-cause mortality rate (substance use being the other).³ While overall lifetime prevalence rates are estimated to be between 1 and 5 percent⁴, we are seeing disordered eating behaviors emerge in younger children.⁵ Since the COVID-19 pandemic, rates of youth requiring medical hospitalization have increased⁶, and there is greater recognition that medical instability can occur across a range of weights in adolescent eating disorders.⁷

My Patient Meets Criteria for Admission, Setting Expectations for Hospitalization

Whether you’ve been monitoring a patient exhibiting signs/symptoms of an eating disorder for several visits or meeting a patient for the first time and observing concerning physical and behavioral symptoms of restrictive eating, it’s important to keep in mind the Society for Adolescent Health and Medicine (SAHM) hospital criteria (Table 1) when gathering history and completing your physical exam. Significant reductions in weight, food refusal, orthostatic changes, electrolyte abnormalities, or bradycardia may be just some of the warning signs that trigger the need to escalate to a higher level of care.

Table 1: Admission Criteria for ED-Related Medical Stabilization

When discussing the need for inpatient hospitalization for medical stabilization with your patient and their family, providing anticipatory guidance and setting appropriate expectations is essential. Regardless of whether this is a first admission for a youth or a return admission secondary to continued medical decline, the patient and family are likely to experience a myriad of emotions, including fear, anxiety, and sadness. While some patients and families may experience a sense of relief and appreciation knowing they will receive more intensive support and assistance to address the resulting health complications, patients often deny the need for aid and remark that they feel just fine. Recognizing that the eating disorder is likely driving these reactions and that the malnourished brain maintains these behaviors, psychoeducation is paramount. However, education without empathy and validation may not be successful. Therefore, it is essential to validate these emotions when communicating the necessity of a medical hospitalization, as hospitalization can be lifesaving.

Providing a clear rationale can facilitate family understanding and acceptance when recommending hospitalization. Using data to support your decision can be helpful. For example, “Your heart rate is 41 beats per minute, which means you are bradycardic, a low heart rate. This change in your heart rate has occurred because your body has not been receiving enough nutrition to support you, and your weight is declining. Therefore, your heart is slowing down to conserve energy. I recommend hospitalization to replenish your body and improve your heart’s functioning.”

Communicating the seriousness of the medical complications of the eating disorder, regardless of the type of eating disorder, will help to ensure action. It is helpful to affirm that you, as the youth’s physician, are on their team to ensure they are safe and healthy. The patient and family should not view hospitalization as a punishment or consequence for inaction or failure; instead, it is a necessary step to stabilize the youth medically and to help set the youth on a path of nutritional resuscitation, which will then allow for greater engagement or participation in specialized eating disorder treatment. This messaging may need to be repeated to set appropriate expectations for what will occur during hospitalization, and consistent reinforcement of this perspective will need to be reinforced at admission and throughout the hospital stay. The primary goal for hospitalization is medical stabilization. Therefore, the primary diagnosis for admission should reflect the medical complications that are present (e.g., bradycardia, severe malnutrition, syncope, hypotension) for which the patient is receiving care, rather than the eating disorder itself (e.g., Anorexia Nervosa, Avoidant/Restrictive Food Intake Disorder).

We’ve outlined what you might expect for your patients from the time they first present to the Emergency Center (EC) through hospital discharge. This information serves as a general guide, recognizing variations/deviations may occur and is facility- and patient-dependent.

I’ve Recommended Admission. Now What?

At your recommendation, the family will need to present to the Emergency Center (EC) unless you can admit them directly from your office. The family should communicate the reason for presenting to the hospital (e.g., “I was sent to the hospital because my child was seen by their primary care physician today and found to be bradycardic and has lost 20lbs in the last month”). You should encourage the family to share a thorough history of their concerns and their teen’s disordered eating behaviors and routines. Families should also share the disease management to date, if any. Following the clinical interview and physical examination, if your patient meets the criteria for hospital admission, the provider will discuss the next steps and provide a brief overview of what the family can expect during hospitalization. As the primary care provider, you can help this process by calling the EC physician evaluating your patient to discuss the need for admission.

While hospital admission may vary by facility, families can expect a multidisciplinary approach to their child’s care, with each team member playing a vital role in addressing the patient’s unique medical, nutritional, and psychological needs.^9-11 The care team will likely include nurses and patient care technicians, physicians/practitioners (e.g., hospitalists, adolescent medicine physicians), nutritionists, and behavioral health team members (psychology, psychiatry, and/or social work). This interdisciplinary team collaborates closely to provide comprehensive and optimal care, with the primary goal of medical stabilization.

Depending on the inpatient facility, there may or may not be a clinical pathway to guide patient care. Clinical pathways are developed by organizations based on evidence-based medicine¹² and outline best practices to facilitate high-quality, standardized clinical care, while allowing for independent clinical decision-making to serve each patient’s best interest. Families are provided information related to the Eating Disorder Pathway or Protocol (terminology varies by facility) at the time of admission, which is revisited throughout the admission to ensure understanding and clarify any questions or concerns.

As the primary goal for hospitalization is medical stabilization, the primary focus of the clinical care plan will be on medical management and nutritional rehabilitation to reverse the effects of severe malnutrition and restore vital sign stability.¹³ Medical monitoring by the providers caring for the patient will occur daily. Depending on the institution, this will likely be the hospitalists or adolescent medicine physicians. These providers are responsible for the overall management of your patient’s care. Based on their evaluation, the treatment team may implement additional interventions, such as adjustments to caloric intake, electrolyte repletion, or further diagnostic assessments to monitor organ function and identify potential complications related to malnutrition. Nurses should obtain daily (in the morning) blinded weights with the patient in a gown and their back to the scale readout to assess progress and inform changes to the nutrition plan. Ensuring the patient is in a gown during weigh-ins limits variability between measurements and reduces opportunities for inflating one’s weight. Early morning weights minimize the chance of “water-loading.”

One primary concern about the nutritional rehabilitation of a patient with an eating disorder is refeeding syndrome. Malnourished individuals must rely on fat and muscle to survive, as they have depleted glycogen stores. When refeeding begins, the body quickly resumes using glucose as its primary energy source. Glucose metabolism creates the need for phosphorylated intermediates in the Krebs Cycle and electron-transport chain, with the products of these reactions, 2,3-diphosphoglycerate and adenosine triphosphate. Serum phosphorus (and thiamine) levels can be depleted rapidly in this process, leading to cardiac arrhythmias or failure, renal failure, hemolysis, delirium, coma, and, sometimes, sudden cardiac death. This event can happen as late as two weeks after initiation of refeeding.^14,15

Due to the fear of refeeding syndrome, the standard of care has historically been lower-calorie refeeding, starting at approximately 1000-1200 kcal/d and gradually increasing to minimize the risk of refeeding syndrome.¹⁶ This plan follows the adage “Start low and go slow.” Recent studies have documented that refeeding syndrome is likely more related to how severely malnourished your patient is than how quickly refeeding occurs.¹⁷ When a person is severely underweight, the staff will sometimes start supplementation of phosphorus and magnesium on admission, as well as thiamine and folic acid.

One can easily see why treatment teams develop a weight restoration nutritional plan early in the hospital course, considering a patient’s age, height, growth trajectory, and pubertal stage. Currently, higher-calorie refeeding, starting at 1400 kcal/d or more, has been examined more recently to accelerate weight restoration and reduce lengthy hospitalization (except in severely malnourished individuals with a mBMI of less than 72%). One randomized controlled trial for adolescents and young adults with anorexia nervosa and atypical anorexia nervosa found that higher-calorie refeeding demonstrated short-term efficacy without an increase in safety events.¹⁸ Safety remains the top priority regardless of the method employed, and electrolyte monitoring and correction are critical. Families should be informed labs will likely be drawn daily or even twice daily to start and later spaced out to monitor for refeeding and determine whether any supplementation needs to occur.

The nutritionist selects meals to ensure the patient meets their nutritional needs. Facilities may establish specific guidelines around meals to support patient success. Typically, staff will allot a 30-minute time frame for meals and 15-30 minutes for snacks. Patients should empty their bladder before eating their meals because staff will enforce a rest period after the meal to prevent the patient from purging or exercising in the bathroom. Mealtimes are limited to allow patients to have breaks between meals, facilitating feelings of hunger and providing for other enjoyable or necessary activities throughout the day.

Nasogastric tube (NGT) feeding may be initiated as part of achieving nutritional goals for patients with eating disorders. However, there is no consensus regarding the timing or criteria for initiating NGT feeds. For instance, some physicians initiate them when patients are unable to complete their meals. Others utilize NGT feeding exclusively at the outset or with oral nutrition. Research indicates NGT feeding can lead to faster medical stabilization and weight restoration among this patient population, thereby reducing hospital length of stay.¹⁹ Before discharge, meal completion (e.g., often three meals and two snacks, but may be more depending on caloric needs) is a goal to ensure safe discharge.

Hospital staff should monitor fluid intake and total volume restricted to maintenance levels to facilitate feelings of hunger and minimize weight distortion. If a patient cannot complete their meal within this period, the nurse may offer an oral nutritional shake or administer one through their NGT to meet caloric requirements. In the event patients cannot transition to oral nutrition, they may be discharged to a specialized eating disorder facility that can manage NGT feeds and/or continue medical stabilization and nutritional rehabilitation.

For patient safety, youth are typically monitored 24/7 during their hospitalization, assuming the hospital has the staff to do so. While there are different monitoring modalities, such as video monitoring, frequent nurse check-ins, or a constant patient observer (CPO), the focus is on ensuring patient safety and monitoring for disordered eating behaviors. A CPO, when utilized, is responsible for keeping eyes on the patient to ensure they are receiving the nutrition (e.g., not clamping NGT, discarding or hiding food). They will limit bathroom usage immediately after meals (up to 1 hour) to avoid opportunities for purging. Additionally, CPOs are responsible for limiting physical activity to prevent the patient from being too active and preserve nutrition for weight restoration. Patients are monitored for subtle energy exertion behaviors, including standing for prolonged periods, stretching, abdominal crunches, and running in the shower. During their check-ins, nurses in some centers check the patient’s pulse after they use the restroom or when they are alone. Setting the room thermostat to the middle reduces a patient’s likelihood of burning calories from being too cold or too warm.

Brief Psychological Interventions

Psychological supports are likely to be provided during hospitalization to help facilitate coping with medical stabilization and nutritional rehabilitation, provide psychoeducation, and begin to introduce the family to evidence-based treatment for eating disorders. Inpatient mental health providers are typically in a consultative role during hospitalization. They start by completing a biopsychosocial assessment to enhance their understanding of the clinical presentation and its impact, and then provide psychological support during hospitalization. In general, mental health providers aim to validate the emotional challenges of hospitalization, introduce coping skills and relaxation techniques, and address uncertainty about what may follow after discharge. Where appropriate, psychological supports may utilize evidence-based approaches, such as cognitive-behavioral therapy, to address maladaptive thought patterns associated with the eating disorder, body image concerns, and emotions related to the reintroduction of meals. However, these interventions will be limited by a patient’s medical status and malnourished state. Also, dependent on the patient’s medical status, psychiatric providers may be consulted during the youth’s hospitalization to address comorbid psychiatric symptomology or adjust existing medication regimens.

In addition to supporting patients, empowering parents and caregivers is critical to the psychological intervention process. Drawing from the principles outlined by Anderson and colleagues²⁰, inpatient mental health providers work closely with families to enhance their confidence in managing their child’s eating disorder at home. Providing psychoeducation helps equip caregivers with tools to reinforce recovery behaviors, provide meal support, and create a structured and supportive environment after discharge. Moreover, empowering parents fosters collaboration and helps caregivers feel more prepared to take an active role in their child’s recovery, which will be essential for long-term success.

A collaborative and integrated approach among the healthcare team ensures they meet the patient’s nutritional and psychological needs. This multidisciplinary approach addresses all aspects of patient recovery, encompassing medical and dietary needs, psychological support, and social considerations.²¹ Additional care team members may include Child Life Specialists who can assist with normalizing the hospital environment and behavioral activation by supplying preferred activities for engagement. Hospital schoolteachers can also provide support during admission by coordinating with the patient’s school and assisting with assignments. Music therapy can provide an opportunity for emotional coping through artistic expression and diversion. Supportive services can help alleviate some of the boredom that patients and families report during admission and can provide structure and routine to the day. However, it is essential to recognize that psychological support during the patient’s hospitalization is not sufficient to treat the underlying eating disorder. Experts recommend evidence-based treatment following discharge. Next, we provide a brief overview of specialized eating disorder programming to inform your conversations with families regarding the next steps after hospitalization.

My Patient is Almost Ready for Discharge: Post-discharge Planning Begins

The usual length of stay for medical hospitalization is between 1 and 2 weeks, but it often varies by illness severity. Before hospital discharge, your patient must exhibit normal serum chemistries for at least 24 hours and be medically stable (e.g., with an improved heart rate, normal temperature, and without symptomatic orthostasis or edema). Depending on local resources, physicians might discharge your patient to outpatient care, a partial hospitalization program, an intensive outpatient program, or a residential eating disorder treatment facility.²² For medically and psychiatrically stable patients, outpatient treatment is the current standard of care.²³ Within this issue, we encourage the reader to review the article by Drs. Reese and Sobalvarro for information pertinent to Family-Based Therapy, considered to be the first-line treatment for Anorexia Nervosa.

Conclusions

This paper outlined the key components of care for youth admitted to a hospital setting with eating disorders. The purpose is to provide a general guide for medical providers on what to expect when caring for patients requiring medical stabilization. We hope this framework will help healthcare providers understand the typical course of treatment while acknowledging that variations may occur depending on the facility, care team, and individual patient needs.

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