Patients with a sensory restrictive eating disorder admitted to acute hospital wards

Acute hospitals can be the right location to support patients with an eating disorder, including when they have short-term, urgent medical needs. However, the right adjustments are needed to support a helpful admission. 

We have made this document to support re-feeding admissions on acute wards. This includes giving practical advice and tools you can use.

A guideline for professionals is available to help direct medical staff. This is called the Emergency re-feeding plans: for patients with a sensory restrictive eating disorder admitted to acute hospital wards. The guideline for staff includes advice on risk assessment, re-feeding and medical management. A copy of the ward staff guideline is available via the dietitian or local mental health team.

Alternatively, ward staff can contact: clare.ellison@cntw.nhs.uk (lead author) for a copy. 

This document supports the staff guideline. It is for patients (or their families) admitted to a hospital ward for treatment for their sensory restrictive eating disorder. This is when a person restricts their eating because of the sensory properties of the food and/or environment.

These individuals would usually need adaptations for their sensory differences. These adaptations would support an effective admission. 

This document is not intended to support those with anorexia nervosa. This is because different eating disorders differ in how they are best treated. However, you can use this document to support and inform sensory adaptations for those with anorexia nervosa who may also have autism or sensory difficulties These patients should have reasonable adjustments made to their treatment and care (Cobbaert and Rose, 2023) to support a sensory-sensitive treatment approach.

This guidance aims to equip patients and families with some practical tools. You can give these to the ward staff yourself. This can help you to feel more in control of your admission.

Reasonable adjustments are mentioned a lot throughout this document. We also use this term in the guidance for staff.

An adjustment is when your care team make changes to your treatment to accommodate your specific needs. Adjustments help to ensure that any treatment you receive is effective. They also minimise any potential harm or disadvantage.

Reasonable means that the adjustment is appropriate to the care setting. This means that it could be achieved on an acute ward.

Reasonable ensures that any adjustments are still able to comply with hospital policy: meaning the ward is still able to deliver safe, life-saving treatment according to the clinical need.

Malnutrition describes a person who has not been getting the nutrition and energy that their body needs. Re-feeding describes a person with malnutrition who starts to feed again.

Refeeding syndrome is the name of a dangerous medical syndrome. This is something that can happen to some malnourished people who start to consume nutrition again.

The risk of developing re-feeding syndrome is complex. Your risk is calculated by qualified healthcare professionals (like dietitians and doctors). Your risk depends on things like how long you were malnourished for, how little you were eating, and your current weight or weight loss.

Re-feeding syndrome is a series of chemical reactions in the body. It is dangerous because it changes the chemical levels in your blood which can affect your heart rhythm.   

To manage the risk of developing re-feeding syndrome we use scientific evidence and guidelines. Current evidence suggests using a mineral called thiamine.

Thiamine should be prescribed daily and for the first 10 days of re-feeding, alongside an age appropriate multivitamin and mineral. These medications help to keep the heart beating normally. This can help to prevent you from developing re-feeding syndrome.

A medication called Forceval is the preferred option of multi-vitamin and mineral. Forceval is available as a tablet or soluble-tablet (called an effervescent). It is also available for both adults and children. Forceval is preferred because it is usually available on the wards and it is ‘nutritionally complete’. This means that it provides all the vitamins and minerals that the body needs. 

For people with sensory restriction, taking a multivitamin is not usually straightforward. This means that it is not as easy as taking the recommended version and it can present challenges. 

If you or your loved one is not able to take Forceval you should discuss alternative options with the ward staff. Some examples of alternative options to consider together might be: 

• Liquid multi-vitamin (such as Abidec multivitamin drops for babies and children or ketovite liquid in adults) 
• Other dissolvable preparations (such as paediatric Seravit) 
• Chewy multi-vitamin/mineral (such as age-appropriate Centrum fruity chewables) 
• Vitamin spray (such as BetterYou MultiVit oral spray for those aged >13 years) 
• Vitamin sprinkles (such as Nutrigen Vitamixin for children and young people) 
• Spatone liquid iron (if applicable) 
• Chewable calcium, such as calcichew (if applicable)

Please do not bring any medication onto a ward without agreement from the ward staff. This includes multivitamin and mineral supplements. This is because it can be very dangerous. Sometimes, it is not possible to prescribe alternative options, in which case staff may give special permission to bring agreed alternatives onto the ward with you. 

Side-room admissions are generally preferable. Side room admissions reduce the total sensory input compared with a ward or bay. This means that the sights, sounds, and smells are fewer. Where possible, using rooms with blinds and neutral colours are preferable. Where possible, separate sensory-friendly spaces are also welcome. Unfortunately, these are not always available. 

Hospital staff should be mindful of monitors, trolly sounds and making noise when walking past. They should try to minimise this wherever possible. However, there are often many limitations within the ward setting which make this difficult. 

If a side room is unavailable, it may be possible to adjust your location within a bay to make it more helpful. This could include being closer to a window or further away from a bathroom or nursing station. Ideally any location moves would be planned and wouldn’t take place unless necessary. 

Sensory eating difficulty admissions are not driven by weight/shape concern and weight loss. This means that individuals have not been restricting their eating to lose weight. Therefore, staff need to support those with sensory restrictive eating difficulties differently from those with anorexia. 

If you use vomiting to regulate your emotions (rather than to lose weight), this should be discussed with your care team. You should think together about how this risk could be managed or minimised. Think together about what would need to be put in place to safely support, or reduce, this behaviour. 

The use of a wheelchair and bed rest should only be used if it is medically necessary for your safety. This is because confined movement for a sensory-sensitive person can be extremely difficult. Movement for these individuals is not driven by trying to lose weight.

However, it can often have this unintended consequence. An unintended consequence means that weight loss could happen as a result of movement, but this wasn’t the intention. Because movement can have this unintended consequence it can increase your health risks. We recommend sharing with the ward about how your sensory needs are best managed. This includes any use of movement to regulate your arousal (emotions).

You and your medical team can then consider and agree safe options for supporting this.  Example supportive management examples might include: 

• Permitting 1 minute of pacing in the room before or after meals  
• Supporting an environment that enables you to eat standing up 
• Using physiotherapy balls to support movement whilst limiting energy expenditure 

Full meal supervision or observation is also not routinely recommended. Instead, the following questions should be considered by you and your care team. These can help to support you in creating an ideal eating environment, which can help to reduce your anxiety: 

1. Is there any unwanted sensory stimulus that may cause distress or discomfort before, during or after mealtimes?  
2. Do you prefer to eat with other people? If so, who might this be and can the ward accommodate this person visiting during meal times? 
3. Do you like people to talk to you and encourage your intake? Or do you prefer to eat in silence? 
4. Do you prefer to watch your favourite TV show, use a tablet device or listen to music whilst eating?
5. Does it help you to wear noise cancelling headphones? 
6. Does it help you to eat alongside reading, puzzles or other distractions such as tablets and radio? 
7. Does your chair have to face the door? Or a specific direction? 
8. Do you prefer to have the curtains closed (if in a bay)? 
9. Can other people touch/prepare your food? Such as others removing lids from food pots. 
10. Does it help you to eat standing, on a beanbag, on or against a hard surface, or sitting on a physiotherapy ball for meals?  
11. If you are sat in a chair, is it of an appropriate size and support? (e.g. can this be modified by adding blankets and cushions to enable you to feel tight and secure in your chair? or raisers placed under your feet as a footrest to make a more stable position for eating?) 
12. Do you prefer to eat in your room or an alternative location? 
13. Do you prefer to be served first or last? Or at a specific time (if possible)? 
14. Do you prefer to eat with your hands? 
15. Do you prefer to eat outside usual mealtimes?
    
    Additional questions for children and young people: 
16. Does it help when the person with you models eating (eats the same food with you)? Or do you prefer to eat alone? 
17. Do you prefer it when someone sits next to you? In front of you? 

Thinking these through, sharing them with staff, and writing them down can all help the ward to 
support you in your preferences. 

I found it very difficult eating in a bay with other people also eating due to the smells and noise, plus ward mealtimes are typically chaotic. It helps pulling curtains around but for cold meals I chose to eat these outside of the typical mealtimes when it was quieter and less smelly! (patient with lived experience) 

Try to consider broader options about how your food is managed in hospital. This means thinking about how your food can be presented so it looks the same. Or how it could be made more acceptable to you (e.g., using specific brands or being kept separate on the plate). It also includes thinking about the type of crockery and cutlery used.  

The checklist below can be used to support your re-feeding menu. It should be completed by you (or your family, as appropriate). It is intended to support your experience and provide guidance to the ward staff. It should be printed and kept in the appropriate place in your care file. Ward staff can then refer to this throughout your admission: 

This document is unlikely to cover everything that you consider to be helpful. Please use the extra lines to add anything else important or useful to you. You can also add more lines or use a separate sheet of paper. You may find that showing a picture of how you usually like your food to be presented is also helpful. 

Further information on supporting sensory eating difficulties can be found from: PEACE Pathway – Supporting Eating Difficulties.

Self-regulation means ways in which you manage your difficult feelings and emotions. Self regulation strategies are very different for different people. They depend on your own unique sensory profile. Your sensory profile is often best completed by a specialist sensory Occupational Therapist (OT).

However, a useful and simple starting point comes from sharing information. You (and your family) should make a note of any strategies that you use which help you/your child to self-regulate. You can then share these with your care team.

Although this list won’t apply to everyone, the checklist (below) can be used to support you in communicating your self-regulation needs. It should be completed by you (or your family, as appropriate). It should be printed and kept in the appropriate place in your care file.

Ward staff can refer to this throughout your admission:

This document is unlikely to cover everything that you consider to be helpful. Please use the extra lines to add anything else important to you. You can also add more lines or use additional sheets.

In some cases, occupational therapy (OT) departments may be able to support some equipment needs. However, in most cases they will need to be brought onto the ward from home. Anything you bring from home will need to be agreed with the ward.

They must ensure that it complies with their health and safety policy for the safety of all patients. It can be frustrating if something you find helpful isn’t allowed. Therefore, try to discuss what is helpful and why, and what you’d like to bring in with you in advance. Your ward should try to support these items, but it may not always be possible.

Patients admitted with sensory restrictive feeding difficulties often feel anxious and concerned. This is a very unpleasant feeling and experience. Many patients have also had previous experience of feeling unheard, judged or blamed.

All staff should treat you with kindness and respect. They should try to be empathetic to the challenges you are facing. The ward staff should also make reasonable adjustments in their communication with you, especially if this helps to better support you. Ensuring that their communication with you is accessible and helpful is very important.

Although this list won’t apply to everyone, the checklist below can be used to help you tell staff about your communication needs. The staff can then use this information to better support you.

The checklist should be completed by you (or your family, as appropriate). It should be printed and kept in the appropriate place in your care file.

Ward staff can then use this throughout your admission:

This document is unlikely to cover everything that you consider to be helpful. Please use the extra lines to add anything else that is important or helpful to you. You can also add more lines or use additional pages.  

A social story is a simple, clear description of a certain situation, event, or activity. They include the steps involved in the process and what the person might feel or experience. Social stories can be helpful because they support the safe and meaningful exchange of information. They can help people understand and feel more comfortable in facing new or challenging experiences. 

Naso-gastric tube feeding is the process of inserting a feeding tube into the nose that goes down into the stomach.

This procedure is sometimes necessary for medical purposes and managing significant risks.

Inserting a naso-gastric tube can be a difficult and distressing procedure for anyone. This is especially true for a person who is neurodivergent or sensory-sensitive. To support as positive an experience as possible, your care team should allow you to be in a sensory-safe environment. This means an environment with dimmed lighting, and one which is quiet. There should also be as few people present as possible during the procedure. Ideally, those present should be individuals you are already familiar with. Inserting a naso-gastric tube can be very overwhelming from a sensory perspective. Being in a safe, low-sensory environment may help to lessen a potentially traumatic experience.

Your care team should discuss the possibility that a naso-gastric tube may be necessary as early as possible. Discussing this at the beginning of your admission may be of benefit and help you better prepare. Some medications can also be used to help you feel more relaxed or to reduce your memory of the process. All medication options must be discussed with you in full. This includes details about their risks and benefits. This information should be communicated with you in a way that you understand.

Unless there is a legal reason, the use of medication and naso-gastric tube feeding will be your choice. Legal reasons include being treated under the mental health act or mental capacity act. If this is the case, you will be made fully aware and informed of this process from the start.

Appendix 1 has an example of a social story to support your understanding about the process of having a naso-gastric tube fitted.

Naso-gastric tube feeding is most usually used when other oral methods of re-feeding have not been possible. This could be for a variety of reasons. An example of a social story about the steps involved in nutrition progression can be found in Appendix 2.

Supporting the explanation of the nasogastric tube process with visual aids can also be helpful. Visual aids are things like pictures or videos or being shown the equipment. These are not always possible but if you think it would help, please ask your care team if it is available. If you have prior experience of naso-gastric tube feeding please share your experiences with your care team. This helps give them information about any preferences-by-experience that you may have.

Hospital wards always include changes in staff and a process called staff handovers. This is where staff share your information and any recent updates with their next colleague.

It’s important that all your information is handed-over between those working shifts. This helps to reduce how many times you have to tell your story to different people. This helps you to feel heard and helps to develop trusting relationships.

Unfortunately, staff handovers can be time pressured. When this happens, despite best intentions, handovers are not as detailed as we’d like. Because of this, we have created an example template below that you can complete and print.

This can be kept confidentially inside your hospital notes or files. Or, with your consent (agreement), it can be printed and put onto your hospital door. Printing and displaying this ‘patient needs’ template can work as a practical reminder to all staff before they enter your room.   

To use this template: staff complete the timings for protected mealtimes in the box below. You (and your family) select your preferences from the list of sensory sentences below. You should delete/cross-out any which do not apply or make sense to you. You can also add any others of your own into the box.

When a person has a sensory restrictive eating disorder, their food preferences are usually very unique to them. This makes it very difficult to create an example or emergency plan.

Although we know this, hospital wards need guidance to help start the re-feeding process. This is essential because it is necessary to keep you safe. This is especially important if you are admitted when there are no specialists available. This is because specialists can help create your individualised plan. There are less likely to be specialists available during a weekend or a bank holiday.

Having a ‘standardised’ re-feeding meal plan available at these times helps to stop people from becoming more unwell. Example re-feeding plans are therefore available in the staff version of this document. This is called 'Emergency re-feeding plans: for patients with a sensory restrictive eating disorder admitted to acute hospital wards.'

Within this staff guidance, we have tailored these example plans for people with sensory selective eating disorders. The ways in which we have done this are as follows: 

Using naso-gastric tube (NGT) feeding

It is recommended to initially feed a small amount over a longer period. This helps manage blood sugar levels. It also reduces the feeling of nausea and fullness, especially in those with sensitive interoception.

Using nutritional supplements

Nutritional supplements are drinks containing lots of nutrition in a ready-made pre-bottled drink. They can be a very helpful tool. They can help ensure that a patient consumes enough energy, protein, vitamins and minerals. This can be especially helpful for those who require liquid nutrition. This could be due to fears of choking, for example. It can also help those who can only manage small volumes of nutrition due to sensitive interoception.

Nutritional supplements can be helpful because they are highly consistent. This is useful if you struggle with taste and texture variation. They can also be helpful for a person who may be avoiding foods due to fears of contamination. This is because they are pre-packaged and ready-sealed. Supplement drinks can be used as the only source of ‘food’. Alternatively, they can be used alongside a food or naso-gastric tube feeding plan.

For those with sensory eating difficulties we recommend using a high calorie per millilitre version. This keeps the volume low and helps manage any feeling of sickness. Neutral flavours (e.g., neutral or vanilla) may be better tolerated. It would also be recommended that they are served cold as this can reduce the smell and taste. 

Oral nutritional supplements can be given in their original bottle, with a straw. Alternatively, they can be decanted into your own preference of drinking cup. Ice can be added (if helpful and available). 

Some people may struggle to tolerate large doses of supplement (e.g., 6 times per day). If this is the case, we have suggested that these are split into smaller, more frequent doses. This can better suit those feeling extreme fullness or sickness. Timings for giving supplements should be clear. This is especially important if you are using a frequency which differs from the ward’s usual medication routine.   

We recommend that the full range of available supplement options is discussed with you. This can increase the probability that you will find a version best suited to your sensory preferences.

Ward staff should make sure that your preferences are documented and included in their handover. This should include details about your preferred flavour and temperature. It should also include details about how you like supplements to be served.

Using food

The oral food plan was created using guidance from the award-winning PEACE Pathway menu. It is intended to give a broadly sensory-accepted menu preference, at specific mealtimes. However, we know that it will not meet the unique sensory preferences of everyone. In many cases, specific foods will need to be brought in from home (such as branded items). This is often due to catering limitations. These alterations should be discussed with the ward staff. Where possible, they should help to support reasonable adjustments for these.

Alternative milk options (e.g. non-dairy) are another example of a reasonable adjustment.

Within the staff document version, there is also an alternative plant-based re-feeding plan available.

Working with common co-occurring behaviours

Within sensory-restrictive and neuro-diverse patients we often notice obsessive and/or compulsive behaviours (Rhind et al., 2014; Dell’osso et al., 2024). These can include contamination fears and/or practicing specific food routines. These behaviours help to increase the sense of safety around food for an individual. Staff can help you to manage these anxieties by ensuring that you know where your food is stored. Knowing how you can access it, and how it is kept safe and uncontaminated can also help.

Where obsessive and/or compulsive behaviours are observed, it is important to include the mental health team. The mental health team can help support and develop an understanding of these behaviours. This understanding can then be included into your holistic plan of care. A holistic plan of care is an approach that focuses on the whole person and all their wider needs.