Sample letter 4 regarding young patient not meeting treatment:                                   Download this letter as Word Document

 18 October 2004

RE:  XXXXX YYYYY

DOB: 10/10/2010

To Whom It May Concern:

I provide care to XXXXX YYYYY for medical complications related to an eating disorder. XXXXX’s eating disorder is characterized by significant food restriction, excessive exercise, with resultant bradycardia, poor perfusion, constipation, and cold intolerance.  XXXXX has now lost more than 23 pounds (at a time when she should be growing and gaining weight), and her weight continues to drift downwards.  She is now significantly underweight with a body mass index of 15.5 (12th percentile).

XXXXX acknowledges obsessive compulsive thinking about her eating, weight, and exercise, but is willing to try to make changes.  While XXXXX does not meet the criteria for anorexia nervosa, she does meet DSM-IV-TR criteria for eating disorder, not otherwise specified of a restricting anorexic subtype. On a positive note, XXXXX recognizes that things have spun out of control for her and seems willing to make efforts to try to improve her health. 

XXXXX has made little progress despite 10 weeks of intensive outpatient psychotherapy, nutrition counseling, and medical monitoring.  Therefore, XXXXX’s treatment team is unanimous is believing that hospitalization is required to address XXXXX’s disorder.

Unfortunately, the request for XXXXX’s hospitalization has been denied on the grounds that XXXXX does not [yet] meet the formal criteria for anorexia nervosa,  These criteria, however, are not applicable to someone of XXXXX’s age.  In fact, the standard of care for young patients with eating disorders is for aggressive treatment so as to potentially avoid further entrenchment of her illness, and the significant long-term complications associated with a protracted course (see references below).

We respectfully request a re-review of XXXXX’s case.  We would be happy to speak with the reviewing psychiatrist and pediatrician.

Please feel free to call with any questions you might have.  I can be reached at 555.555.5555 or by e-mail at RRRRR@MMMMM.edu.

Sincerely,

RRRRR SSSSS, M.D., M.P.H.

Clinical Professor of Pediatrics

Chief, Section of Teenage and Young Adult Health

---

• "To avert potentially irreversible effects on physical growth and development, many children and adolescents require inpatient medical treatment even when weight loss, although rapid, has not been as severe as that suggesting a need for hospitalization in adult patients."
  Rome ES, Ammerman S, Rosen DS, at al.  Children and Adolescents with Eating Disorders: The State of the Art.  Pediatrics.  2003; 111:e98-e108.
  
  
• "Early detection and management of an eating disorder may prevent the physical and psychological consequences of malnutrition that allow of progression to a later stage."
  Committee on Adolescence, American Academy of Pediatrics.  Policy Statement: Identifying and Treating Eating Disorders.  Pediatrics.  2003; 111:204-211.
  
  
• "pubertal delay, growth retardation, or the impairment of bone mineral acquisition may occur at sub clinical levels of eating disorders."
  
  "The use of strict criteria may preclude the recognition of eating disorders in their early stages and subclinical form... abnormal eating habits may result in significant impairment in health even in the absence of fulfillment of formal criteria for an eating disorder."
  
  "Because of the potentially irreversible effects of an eating disorder on physical and emotional growth and development in adolescents, because of the risk of death, and because of the evidence suggesting improved outcome with early treatment, the threshold for intervention in adolescents should be lower than in adults."
  
  Society for Adolescent Medicine.  Eating Disorders in Adolescents:  Position
  
  Paper of the Society for Adolescent Medicine.  J Adolescent Health.  1995; 16:476-480.
  
  
• Even patients who "look and feel deceptively well", and with normal EKGs, may have cardiac irregularities, variations in pulse and blood pressure, and are at risk for sudden death.
  
  "Patients with subsyndromal anorexia nervosa or bulimia nervosa who meet most but not all of the DSM-IV-TR criteria (e.g., weight > 85% of expected weight, binge and purge frequency less than twice per week) merit treatment similar to that of patients who fulfill all criteria for these diagnoses."
  
  American Psychiatric Association.  Treatment Recommendations for Patients with Eating Disorders.  Am J Psychiatry.  2006; 163(7 suppl):1-54.
  
  
• Adolescent girls with anorexia nervosa being treated as inpatients had decreased brain volume affecting both grey matter and white matter.  Subjects had only relatively brief illness duration.  Brains changes have been shown to be somewhat reversible, but the extent to which these changes are fully reversible is unknown.  Cognitive deficits are known to be present in malnourished patients with AN [anorexia nervosa].  The extent to which these changes are correlated to short-term and long-term cognitive impairments has not been adequately studied nor has the extent to which adequacy of re-feeding affects the reversibility of cognitive or structural brain changes.  "Early and aggressive treatment is essential" to minimize the potential long term physical consequences of this disorder.
  
  Katzman DK, Lambe EK, Mikulis DJ, et al.  Cerebral Grey Matter and White Matter Volume Deficits in Adolescent Girls with Anorexia Nervosa.  J. Pediatrics.  1996; 129:779-781.
  
  Katzman DK and Zipursky RB.  Adolescent with Anorexia Nervosa: Impact of the Disorder on Bones and Brain.  Annals NY Academy of Sciences.  1997; 817:127-37.