Eating disorders: do rigid age limits for paediatrics serve our young people?

“History will judge us by the difference we make in the everyday lives of children.”¹ – Nelson Mandela

We were recently in the position of trying to find an appropriate inpatient bed for two complex eating disorder patients aged 16 and 17. Although discussions were held, paediatrics declined on the basis that they were outside the age limit for their service. As general physicians, we respect the rights of our paediatric colleagues to work within their guidelines. However, we wish to raise concerns about the use of fixed age limits that may deny younger patients an appropriate standard of care that cannot be provided on general medical wards. We document the inconsistency in age limits that exists between region and speciality and describe the capacity, design and resource issues that currently compromise standards of care on medical wards. We emphasise that paediatrics should not be responsible for the lack of investment in adult medical wards or—like us—be expected to manage patients with primary psychiatric disorders. However, we suggest that a more flexible approach such as the patient-centred “like in age and interest” model used in geriatrics may better serve our young people.

Lack of consistency in age limits

Health New Zealand – Te Whatu Ora’s service specification for children and young people defines their population as up to age 18.² For diabetes services this same service specification states that transition to adult services occurs at age 19. This places local variations in the definition of child and young people at odds with broader government documents. Although the Health New Zealand services website is still incomplete, the age cutoffs for children and young people varies by service and region. For example, Canterbury mental health services for children and young people accept those up to age 17, whereas the Bay of Plenty general paediatric service stops at age 15.^3,4 The Starship Hospital eating disorder service accepts those under the age of 17.⁵ The variation in place throughout New Zealand paediatric services suggests that there is no definitive or universal definition of young person.

Bed capacity

Although the variation in definition of a child or young person is interesting in terms of consistency, the greater argument for rejecting a rigid age limit relates to which service is best able to meet the needs of the patient. The Code of Health and Disability Services Consumers’ Rights (the Code) confirms that all patients have the right to services of an appropriate standard.⁶ The Code expands on this to state that an appropriate standard includes services delivered with reasonable skill (4.1) that comply with legal and ethical standards (4.2) and are consistent with patient needs (4.3). This right extends to co-operation among providers to ensure quality of care (4.5).

Wellington Regional Hospital (housing the adult wards) has well-documented issues with capacity and design.^7–9 The emergency department (ED) was one of the most overwhelmed services in New Zealand and bed block within general medicine was nearly constant in 2025.¹⁰ Like in other New Zealand public hospitals, general medicine is the largest admitting unit but admissions frequently exceed bed capacity (Figure 1). General medicine teams routinely round in ED corridors and data show that bed utilisation was frequently over 100% in 2025. During the winter months 10–20 patients would be in the ED waiting for a medical bed to become available at the start of each day.

View Figure 1–4.

Funding has been confirmed for a major rebuild at Wellington Regional Hospital but, bizarrely, there remains no commitment to increasing adult inpatient medical beds (beyond two beds in a medical planning unit) despite clear data that show ageing populations are frequent and disproportionately high users of hospital services.¹¹

By comparison, although the authors recognise that all public services are under pressure, similar capacity issues do not appear to be impacting Wellington’s paediatric hospital, Te Wao Nui, medical wards. Data confirm that the children’s medical ward never breached 100% and utilisation usually runs between 40% and 90% (Figure 2). Adult medical patients frequently occupy the ED, short stay units and other wards as outliers, which increases bed block and wait times not only to medicine but also to other specialty services (Figure 1). Occupancy rates in the adult wards are frequently very high (over 95%), which impedes patient flow especially in the context of workforce shortages (Figure 3). Although the paediatric hospital is also well utilised, the bed occupancy rates are consistently lower, providing for greater flow and less bed block (Figure 4).

Hospitals cannot operate at 100% occupancy as they need spare bed capacity to accommodate variations in demand and ensure patients can “flow” through the hospital. A lack of capacity in terms of bed pressure is also speculated to be a key driver in the unsafe and unethical practice of putting men and women in the same hospital room—a concerning issue for Wellington Regional Hospital.¹² Although there is no universally accepted number, the United Kingdom National Health Service, a public system not dissimilar to New Zealand in terms of resource constraints, has suggested pragmatic maximums of between 90 and 92%.¹³ Our adult wards clearly cannot meet these targets (Figure 3).

Data from Wellington Regional Hospital shows that there were 19 patients between the ages of 16 and 18 with eating disorders taking up 107 bed days in total in the last year. Although only 10 came through the ED, their collective time spent in the ED was 145 hours. Although we don’t have workforce/staffing levels for paediatrics, the occupancy data would suggest that Te Wao Nui would be able to absorb this relatively small number. Admitting directly to a paediatric service would eliminate time spent in the overcrowded Wellington Regional Hospital ED but also enable management to occur on wards that are designed to meet fundamental rights to privacy and dignity.

Appropriate ward design

In terms of design, Wellington Regional Hospital adult wards—like many other hospitals in New Zealand—have a paucity of single rooms. Only 30% of the total rooms are single, meaning the vast majority of patients have to share. The large medical assessment space is also bizarrely open plan, with design resembling curved or L-shaped Nightingale wards. Even more incomprehensible in terms of hospital design is that the shared rooms usually have no doors. The small number of single rooms (with doors) need to be prioritised—clinically and ethically—for infectious disease, delirium, dying and, unfortunately, the behavioural and psychological symptoms of dementia that increasingly complicate admissions in older adults.^8,14

Importantly, due to the insight of the developers and the great generosity of the benefactors, Te Wao Nui has single occupancy design, meaning all patients have access to the privacy and dignity of single rooms. Unfortunately, despite the clear requirements of privacy in the Code and the Health Information Privacy Code, Health New Zealand insists on using flawed guidelines that do not mandate single occupancy.^8,14 This means that new hospitals and builds will continue to have these fundamental flaws built in.

Resourcing for eating disorders

Bed capacity and appropriate design are important in determining where patients should be admitted. However, an appropriate standard of care (Right 4) also relies on training and resourcing.⁵ Eating disorders are complex psychiatric conditions that should be managed by specialist services. However, the paucity of eating disorder beds means that general medicine is expected to admit these patients (regardless of their own lack of beds).⁹ General medicine has been requesting specialist nurses and psychological support (the cornerstone of eating disorder management) for over a decade but still has no resources. Adult wards rely on a consult liaison service that has doubled their referrals in the last decade without any additional resource.⁹ The result is that general physicians and their nurses are pressured to manage eating disorder patients despite having no resources and—frequently—no beds. Although we do not have specific information on pyschological suppport, paediatrics has a specialist eating disorder nurse to provide care and reduce the clinical burden on paediatricians. This doesn’t mean that paediatrics has sufficient resources, but it has more than the complete absence of resource found in general medicine.

Conclusion

The capacity, design and resourcing issues for general medicine are not the responsibility of paediatrics and this article doesn’t seek to suggest otherwise. We ask instead that our hospital services put the patient at the centre of their decision making for admission and service provision rather than use arbitrary age cutoffs. Although these cases are Wellington-specific, we think it is likely that other adult services have similar issues.

We invite our paediatric colleagues to take the more flexible approach long-held by geriatricians, whereby patients are assessed based on whether they are “like in age and interest” and can benefit from their service rather than whether they meet a rigid age cutoff.^15,16 The young people referred will often still be at school, vulnerable and in need of a ward that is fit for purpose, makes them feel secure, protects their privacy and can meet their basic clinical needs. Such patients will be small in number but with a very large capacity to benefit.