Treatment of patients with eating disorders. Couturier J, Mahmood A. Anorexia Nervosa in the Acute Hospitalization Setting Heres How Much Protein You Need in a Day to Build Muscle, changes in fat, glucose, or protein metabolism. A brief historical perspective has been added to better illustrate the center's growth and transformation. 58% of the studies included only examined the effect of NG feeding as a secondary outcome of their study. Extended period NPO (>5 days). Does aggressive refeeding in hospitalized adolescents with anorexia nervosa result in increased hypophosphatemia? Skeletal muscle index (SMI), quantifying muscle mass, was assessed with computed tomography (CT) in 98 patients undergoing esophagectomy. Neiderman M, Farley A, Richardson J, Lask B. Nasogastric feeding in children and adolescents with eating disorders: toward good practice. Exclusion terms: psychiatric disorders other than eating disorders; non-primary research; no outcomes specific to NG feeding and participants over 18years. 3677-3687, Clinical Nutrition, Volume 40, Issue 6, 2021, pp. For nocturnal feeds, oral diet was encouraged during the day. Percent of BG hours in the 4.48.0mmol/L range highest under standard STAR conditions (78%), and was lower at 64% under UL-9, likely due to reduced time-responsiveness of nutrition-insulin changes. Cookies policy. When NG feeding is used under restraint bolus feeds are preferred due to concerns around the tube being removed by the YP once restraint had ceased [45]. DOI: hopkinsmedicine.org/gim/_pdf/consult/refeeding_syndrome.pdf, med.virginia.edu/ginutrition/wp-content/uploads/sites/199/2014/06/Parrish-September-16.pdf. Moreover, for clinicians, there is currently conflicting guidance on how to manage NG feeding in YP with ED, in particular how and when to transition between oral and NG feeding [20, 21]. However, treatment providers should regularly monitor at-risk patients for symptoms of refeeding syndrome. Nasogastric (NG) feeding use in YP with ED may be used as a lifesaving treatment when patients are physically unwell [7, 8]. Naso-Gastric Tube Feeding under restraint best practice guidelines for Dietitians 2019. YP with ED requiring NG were often medically unstable on admission [9, 18, 20, 22, 23, 25, 39] and NG feeding was implemented as standard practice [22, 23, 26, 39]. These studies discussed ceasing NG feeds after the risk of RS had reduced; most gave a time frame between 2 and 14days [24, 44]. Enteral nutrition via nasogastric tube for refeeding patients with anorexia nervosa: a systematic review. As early RFH might impact recovery, it is important to closely monitor phosphate concentrations in patients, especially of those at risk for early RFH. Webreport, literature review and clinical guidelines. Med J Aust. Madden et al [22] RCT determined the duration of NG feeding was a minimum of 14days, using biochemical markers of medical instability in a hospital setting. 2019;8(3):1248. We use cookies to help provide and enhance our service and tailor content and ads. https://doi.org/10.1186/s40337-016-0132-0. This causes insulin secretion to increase. Petkova BH, Simic M, Nicholls D, Ford T, Prina AM, Stuart R. Incidence of anorexia nervosa in young people in the UK and Ireland: a national surveillance study. Mehanna HM, Moledina J, Travis J. Refeeding syndrome: what it is, and how to prevent and treat it. 2016;49(3):293310. 3787-3792, Clinical Nutrition, Volume 40, Issue 6, 2021, pp. Normalization of weight can reverse nearly all of the general medical sequelae of the underweight state, with the exception of bone health [ 3-5 ]. This study aims to examine BG outcomes in the context of nutritional management during GC. The Charlson Comorbidity Index, however, was superior for preoperative risk stratification. WebThe NICE guideline on eating disorders states that there is no international agreement on admission criteria for in-patient care and that thresholds specified vary. Other factors can also put you at an increased risk of developing refeeding syndrome. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. J Eat Disord. Less time spent being underfed may still result in refeeding syndrome if the patient were under, Abuse, neglect, inadequate access to food, Hyperemesis gravidarum or protracted vomiting, Malabsorption (e.g., inflammatory bowel disease, short gut syndrome, s/p bariatric surgery). Advance diet gradually as tolerated. 2020;29(6):118191. This lack of evidence was confirmed by another systematic review and meta-analysis published in 2021. Strik Lievers and colleagues [44] concluded that, amongst others, requirement for NG feeding when NG was implemented due to medical instability was a factor affecting LOS on a psychiatric ward. The anabolic processes require minerals and coenzymes such as thiamine [4,6]. Compared to other mental illnesses, EDs have a high mortality rate with young people (YP) with anorexia nervosa (AN) on average 610 times more likely to die than the general population [4, 5]. Healthcare professionals can prevent complications of refeeding syndrome by: Refeeding syndrome appears when food is introduced too quickly after a period of malnourishment. Nurs Stand. Increase of parenteral nutrition intake (in % kcal of predicted resting energy expenditure) decreased phosphate concentrations (c=0.002 (95% CI -0.002;0.001). Our unpublished survey of doctors, nurses, pharmacists, and dietitians (all members of their respective nutrition societies) on their attitudes to the guidance from the National Institute for Health and Clinical Excellence (NICE)2 showed widespread disparities in practice. Increasing awareness and using screening programs to identify those at risk of developing refeeding syndrome are the next steps in improving the outlook. Nutritional glucose intake affects blood glucose (BG) outcomes, but few protocols actively control it. Maginot et al. https://doi.org/10.1186/s40337-021-00445-1, DOI: https://doi.org/10.1186/s40337-021-00445-1. DOI: Khan LUR, et al. Attitudes to NICE guidance on refeeding syndrome This systematic review sets out to review the current reported evidence of NG in young people. 1 Malnourished Rockville: Agency for Healthcare Research and Quality; 2008. No ethical approval or consent to participate required due to the nature of the study. (2) Hypophosphatemia which occurs within three days of refeeding. You might be at risk if you: Refeeding syndrome is a serious condition. Our study suggests more standardized methods of caloric intake are needed in resource-limited settings with high co-prevalence of PEM and TB. Garber AK, Sawyer SM, Golden NH, Guarda AS, Katzman DK, Kohn MR, et al. To examine the impact of nutritional intake on phosphate concentrations, structural nested mean models with propensity score and censoring models were used. A secondary care hospital in rural India serving a highly tuberculosis (TB) and malnutrition endemic region. 167 (prepared by the Duke University evidence-based practice center under contract no. Crook MA, et al. In 13 studies (3 high risk of bias [28, 35, 47]) in which NG was not implemented as standard protocol for all patients, the percentage of ED YP administered NG feeding in all contexts (due to medical instability or inadequate oral diet) varied between 6 and 66% [9, 18, 29, 31, 36, 37, 41,42,43,44]. See, treatment of established refeeding syndrome, Treatment of established refeeding syndrome, https://traffic.libsyn.com/secure/ibccpodcast/IBCC_EP_83_-_Refeeding_Syndrome.mp3. (2001). WebRefeeding syndrome is defined as the potentially fatal shifts in fluids and electrolytes that may. A blood test that reveals low levels of phosphorus, potassium or magnesium. EMCrit is a trademark of Metasin LLC. Refeeding syndrome: Problems with definition and management. Refeeding Protocol in Anorexia Nervosa Re-examined Finally, factors associated with the incidence of RFS, such as its definition, study design, type of population, age, initial caloric intake, and type of feeding were assessed by subgroup analysis. The exclusion criteria included: No ability to discern results specific to NG feeding, mental disorders other than eating disorders being the focus, where the majority of participants are over 18years or it is impossible to separate results for adults from YP, reviews or other non-primary research and research published before 2000. A systematic review and meta-analyses of literature, https://doi.org/10.1016/j.clnu.2021.04.023, ESPEN guideline on clinical nutrition in the intensive care unit, Restricted versus continued standard caloric intake during the management of refeeding syndrome in critically ill adults: a randomised, parallel-group, multicentre, single-blind controlled trial, Death resulting from overzealous total parenteral nutrition: the refeeding syndrome revisited, Refeeding syndrome in adults receiving total parenteral nutrition: an audit of practice at a tertiary UK centre, The risk of refeeding syndrome among severely malnourished tuberculosis patients in Chhattisgarh, India, Refeeding hypophosphataemia is more common in enteral than parenteral feeding in adult in patients, Incidence and outcome of refeeding syndrome in neurocritically ill patients, Impact of caloric intake in critically ill patients with, and without, refeeding syndrome: a retrospective study, Patients at risk of malnutrition: assessment of 11 cases of severe malnutrition with individualised total parenteral nutrition, COPD patients with acute exacerbation who developed refeeding syndrome during hospitalization had poor outcome: a retrospective cohort study, Refeeding syndrome in patients with gastrointestinal fistula, Management and prevention of refeeding syndrome in medical inpatients: an evidence-based and consensus-supported algorithm, Revisiting the refeeding syndrome: results of a systematic review, Early hypophosphatemia in critically ill children and the effect of parenteral nutrition: A secondary analysis of the PEPaNIC RCT, Impact of calorie intake and refeeding syndrome on the length of hospital stay of patients with malnutrition: a systematic review and meta-analysis, Psychiatric and medical comorbidities of eating disorders: findings from a rapid review of the literature, Evaluation of the ASPEN guidelines for refeeding syndrome among hospitalized patients receiving enteral nutrition: A retrospective cohort study, Refeeding Syndrome: A Critical Reality in Patients with Chronic Disease, Incidence and Impact of Refeeding Syndrome in an Internal Medicine and Gastroenterology Ward of an Italian Tertiary Referral Center: A Prospective Cohort Study, Short-chain fatty acids combined with intronic DNA methylation of. High Protein Feeds in Refeeding Syndrome JM was responsible for references and editing. This is a secondary analysis of the PEPaNIC randomized controlled trial (N=1440), which showed that withholding supplemental parenteral nutrition (PN) for 1 week (late-PN) in the pediatric intensive care unit (PICU) accelerated recovery and reduced new infections compared to early-PN (<24h). Use of High Protein Feeds in Refeeding Syndrome 11 Historically, recommendations for nutritional rehabilitation in inpatient settings have been conservative, 12 16 for fear of precipitating the refeeding syndrome, a constellation of electrolyte disturbances and multiorgan dysfunction that can develop early in the Refeeding syndrome: What it is, and how to prevent and treat it. WebIv or oral multivitamins once daily for 10 days or greater based on clinical status Emad Zarief 2021 29 ASPEN Consensus recommendations for refeeding syndrome. The Refeeding Syndrome (RFS) is a potentially serious, but still overlooked condition, occurring in individuals who are rapidly fed after a period of severe This review aims to assess strategies for the use, tolerance and effectiveness of NG feeding in YP with restrictive ED. Ann Intern Med. https://doi.org/10.7748/ns.2017.e10509. 608 patients (363 female, 245 male, mean age 55.55 year) from all over Poland were treated between December 1999 and December 2019. Different methods of NG may be utilised safely, with NG feeds often given as large bolus, continuously through a pump or overnight in order to supplement daytime oral intake [12, 13]. Glucose intolerance and insulin resistance manifest as hyperglycaemia in intensive care, which is associated with mortality and morbidities. In patients experiencing refeeding syndrome, a dangerous shift in fluids and electrolytes occurs within the body, resulting in compromised cardiovascular status, respiratory failure, seizures and even death. Moreover, refeeding syndrome is seems to be associated with increased 6 months mortality [15]. The average length of stay in patients with refeeding syndrome was 25.55 days with a very high heterogeneity between studies. Nasogastric tube feeding in line with new dietetic guidelines for the treatment of anorexia nervosa in a specialist children and adolescent inpatient unit: a case series. In studies where continuous NG was provided, YP were sometimes not given the option of an oral diet so that their calorie intake could be closely monitored [22,23,24, 31]. Guidelines help identify patients at elevated risk for developing this life-threatening complication of reintroducing calories in the early stages of anorexia nervosa treatment. B12, 1000 mcg PO J Human Nutr Dietetics. Butyric acid levels also correlated with several clinical/echocardiographic factors in DCM patients. Naso-gastric or nasogastric or *enteric or *enteral or tube, (Anorexia or bulimia or eat* or feed*) NOT bowel NOT surgery NOT intestin*, (child* or paed* or adolescen* or teen* or young) NOT baby NOT toddler NOT infant NOT animal NOT maternal NOT parental NOT learning disabl* NOT learning disabil*. Conclusions: The strategy for assessing the risk of refeeding syndrome, nutritional management and implemented follow-up were successful in preventing the Phone: 866.485.6911, 2020 ACUTE Center for Eating Disorders & Severe Malnutrition by Denver Health. Those studies where NG was used for medical stabilisation often described a short period of NG before a quick transition back to an oral diet [22, 23, 36]. This study aids the understanding of clinical nutrition strategies to prevent and treat refeeding syndrome. Death is often caused by cardiac abnormalities associated with extremely low bodyweight [6]. According to these guidelines, patients at the highest risk for refeeding syndrome meet one or more of the following criteria: Patients with anorexia nervosa or ARFID may also have significant risk for refeeding syndrome if they meet two or more of the following criteria: In addition, chronic alcoholism, cancer, uncontrolled diabetes or recent surgery may place a patient with anorexia at elevated risk for developing refeeding syndrome. To keep this page small and fast, questions & discussion about this post can be found on another page here. Some responders thought that NICE guidelines were an obstacle to providing adequate nutrition, while others had never seen a case of the refeeding syndrome despite having always started nutritional supplementation at 100% of estimated requirements. Hindley, K., Fenton, C. & McIntosh, J. Roux H, Chapelon E, Godart N. Epidemiology of anorexia nervosa: a review. Akgul S, Pehlivanturk-Kizilkan M, Ors S, Derman O, Duzceker Y, Kanpur N. Type of setting for the inpatient adolescent with an eating disorder: are specialized inpatient clinics a must or will the pediatric ward do? Our multivariate model could predict EGP at day 4 (VCO2, glucose and energy intake) with an error coefficient (e.c.) Conversely the YP in Paccagnella and colleagues [20] research stated NG was helpful, particularly initially when an oral diet was challenging to manage. Burden of eating disorders in 5-13-year-old children in Australia. WebRefeedingSyndromeDefinitionandBackground. (1) Cessation of nutrition followed by refeeding. https://doi.org/10.1136/archdischild-2016-310506. See additional information. Refeeding syndrome: A literature review. These include: Refeeding syndrome can cause sudden and fatal complications. Until a consensus definition is obtained, the following criteria seems reasonable: (29901461). https://doi.org/10.1002/ncp.10187. References were exported and duplicates were removed using the title and abstract. ssslideshare.com https://doi.org/10.1017/S0033291714001573. Inconsistent study results are partly caused by varying cut-off values used for defining sarcopenia. Bayes A, Madden S. Early onset eating disorders in male adolescents: a series of 10 inpatients. Supplemental nocturnal nasogastric refeeding for better short-term outcome in hospitalized adolescent girls with anorexia nervosa. Agostino and colleagues [23] delivered nutrition on a medical ward solely via NG for 14days before commencing oral diet in addition to NG feeding. DOI: Lambers WM, et al. 2009;190(8):4104. A team with experience in gastroenterology and dietetics should oversee treatment. Cite this article. The incidences of RFS and RH were expressed as percentage and reported with 95% confidence intervals (CI). Andrea Evangelista: Formal analysis; Software. volume9, Articlenumber:90 (2021) None developed clinical RFS. (2008). People who are malnourished are at risk. Long-term effects of enteral feeding on growth and mental health in adolescents with anorexia nervosa--results of a retrospective German cohort study. The 1985;102(1):4952. Arch Dis Child. The refeeding syndrome (RFS) has been recognized as a potentially life-threatening metabolic complication of re-nutrition, but the definition widely varies and, its incidence is unknown. Studies included both male and female patients, however, out of 25 patient focused studies, most had a female majority and 6 studies [20, 26, 37, 39, 43, 44] were conducted on female only cohorts. Many sources recommend starting conservatively (e.g., 50% energy requirement), with gradual advancement. This study sought to (1) determine whether RFS, as operationalized in the 2020 American Society for Parenteral and Enteral Nutrition (ASPEN) guideline definition, is associated with adverse clinical outcomes and (2) identify key risk Refeeding syndrome is an important complication of refeeding in previously malnourished patients [11]. Refeeding Syndrome NICE Guidelines | Medical Algorithm This preliminary exploratory study shows that GNG and EGP have different predictors on days 4 and 10; EGP is more correlated with the metabolic level, while GNG is dependent on external factors. https://doi.org/10.5694/j.1326-5377.2009.tb02487.x. 2009;18(2):7584. Development and validation of risk prediction model for Two main criteria for RFS diagnosis were proposed: 1) a decreasing from 10% upwards of serum phosphorus, potassium, and/or magnesium concentrations and/or the presence of organ dysfunction resulting from a reduction in any of these and/or due to thiamin deficiency; and 2) the occurrence of these impairments within 5 days of reinitiating or substantially increasing energy supplies [1,12]. However, there is no high-quality evidence that this reduces the risk of refeeding syndrome. NG feeding is a safe and efficacious method of increasing total calorie intake by either supplementing oral intake or continuously. Part of Microbiota-derived short-chain fatty acids (SCFAs) affect O2 consumption and play crucial roles in modulating metabolic and cardiovascular health. Robb AS, Silber TJ, Orwell-Valente JK, et al. Refeeding Syndrome 2000;28(4):4705. The underlying health conditions that increase the risk of refeeding syndrome arent always preventable. specialist registrar gastroenterology and clinical nutrition. https://doi.org/10.1002/erv.624. A history of alcoholism or misuse of certain drugs, such as insulin, chemotherapy drugs, diuretics or antacids. The American Society of Parenteral and Enteral Nutrition (ASPEN) has proposed the definition of refeeding syndrome shown below (32115791). Refeeding Syndrome Guideline Research on NG feeding in YP has tended to focus on the acute refeeding phase in paediatric or psychiatric wards to reduce the risk of RS [17]. Online Medical Education on Emergency Department (ED) Critical Care, Trauma, and Resuscitation. Prior to 2017, St Georges Hospitals refeeding guidelines (Figure 2/Figure 3) were not in line with NICE's Nutrition Support for Adults guidelines (CG32). This audit included patients from January November 2017 whereby 51 patients were identified as high risk or extremely high risk and 3 were classed as at risk. It comes after a rigorous review process. Magnitude of gluconeogenesis and endogenous glucose production: are they predictable in clinical settings? Cells need electrolytes like phosphate to convert glucose to energy, but phosphate is in short supply. Eating Disorders: Recognition and Treatment. Nutr Clin Pract. The refeeding syndrome (RFS) is described as a set of metabolic and electrolyte alterations occurring as the result of the reintroduction of calories through oral, enteral, parenteral nutrition after a period of consistent reduction of energy intake or starvation in individuals with pre-existent malnutrition and/or in a catabolic state [ [1], KH and CF performed search of databases and created the document. No study reported a YP developed RS. An essential first step in acute treatment is nutritional rehabilitation (refeeding malnourished patients) and restoring a healthy body weight. During replenishment, the supply of nutrients, above all carbohydrates, results in enhanced insulin secretion, stimulating both glycolysis, the synthesis of glycogen, fats, proteins and increased sodium and water retention [5]. Valentina Ponzo: Data curation, Writing - Review & Editing. 2010;46(6):57782. Refeeding Syndrome - PubMed More well-designed randomized controlled trials are needed to explore the effect of calorie intake during refeeding. Due to the anticipated paucity of studies in this area any research where a meaningful conclusion or result can be drawn regarding NG use in YP with ED will be included. There are a number of limitations to the conclusions that can be drawn from this review. In this study the mean LOS was significantly increased: 117days for YP managing oral intake compared to 180days for those requiring NG. 73 (12.04%) were successfully weaned off PN. The majority also had a relatively small sample size, again introducing the possibility of bias and reducing generalizability. UpToDate Agostino and colleagues [23] demonstrated that YP on medical wards having NG feeds had a mean LOS of 33.8days compared to those in the same setting having an oral diet who had a mean of 50.9days, however, the oral diet was lower in calories therefore taking longer for weight recovery and medical stabilisation. 27 patients were enrolled. Clausen L, Larsen JT, Bulik CM, Peterson L. A Danish register-based study on involuntary treatment in anorexia nervosa. KH gathered data and interpreted results. Youve consumed little to no food, or well below the calories needed to sustain normal processes in the body, for the past 10 or more consecutive days. It seems logical to avoid administering insulin if possible (e.g., allowing glucose to rise to ~200-300 mg/dL). A systematic review of approaches to refeeding in patients with anorexia nervosa. Effect sizes were expressed as 95% confidence intervals (CIs) and calculated using random-effects models. Refeeding syndrome can affect anyone. No unequivocal policy on how to start and progress with HPN has ever been presented. Quality assessment, including risk of bias, was conducted by all authors. All selected studies had an observational design, 23 were retrospective cohort studies [. A blood test has revealed your serum phosphate, potassium, or magnesium levels are low. Int J Eat Disord. PubMed Central Kwashiorkor and marasmus are forms of undernutrition. WebBACKGROUND. However, due to the high heterogeneity of data, summary incidence measures are meaningless. Meal support therapy reduces the use of nasogastric feeding for adolescents hospitalized with anorexia nervosa. Abstracts identified from the initial search were screened in a secondary review process, and full text papers were obtained of those meeting the inclusion criteria or where there was uncertainty. Inpatients were prospectively enrolled. Article Attitudes to NICE guidance on refeeding syndrome - ResearchGate study [18] in a medical ward (where NG was implemented due to insufficient oral intake) discussed NG feeding in the context of YP with more severe medical problems, (such as intractable vomiting and superior mesenteric artery syndrome) which therefore took longer to transition to oral diet, resulting in a longer admission. Scenario: Suspected eating disorder | Management https://doi.org/10.1002/eat.22482. Estimating its occurrence is certainly the starting point to sensitize health professionals to suspect and promptly recognize the RFS. WebRefeeding syndrome consists of metabolic changes that occur on the reintroduction of nutrition to in those who are malnourished or in the starved state (Figure 1). https://doi.org/10.1515/ijamh-2014-0078. A subset of patients receiving high glucose nutrition under IO were persistently hyperglycaemic, indicating patient-specific glucose tolerance. When individuals who are at risk are identified early, treatments are likely to succeed. Halse C, Broughtwood D, Clarke S, Honey A, Kohn M, Madden S. Illumating multiple perspectives: meaning of nasogastric feeding in anorexia nervosa. Home parenteral nutrition (HPN) is one of the most demanding medical therapies as it is the only option for patients for intestinal failure (IF). Results interpreted from studies with a high risk of bias were removed accordingly, leaving only high quality results and conclusions. Restore circulatory volume and monitor fluid balance and overall clinical status closely. Bias can also occur due to the different treatment groups being recorded at different times thus confounding variables may include different staff working at the setting and therefore different methods of treating YP. Anyone you share the following link with will be able to read this content: Sorry, a shareable link is not currently available for this article. Patients who were older (OR 1.14 (95% CI 1.08; 1.21) per year added, p<0.001) and who had a higher Pediatric Risk of Mortality (PIM3) score had a higher risk of developing early RFH (OR 1.36 (95% CI 1.15; 1.59) per unit added, p<0.001), whereas patients in the late-PN group had a lower risk of early RFH (OR 0.24 (95% CI 0.10; 0.49), p<0.001). Nasogastric feeding (NG) is a method of enteral nutrition often used in inpatient settings to treat medical instability, to supplement poor oral intake or to increase nutritional intake. Alternative causes of hypophosphatemia are listed here: Thiamine 200-500 mg IV q8hr-q12hr (use higher dose in the context of any mental status changes, which could reflect the possibility of Wernicke encephalopathy). WebIf the patient is considered to be at high risk of refeeding syndrome, the following steps are advised by NICE (2006): Start nutrition support at a maximum of 10 kcal/kg/day, Nutr Clin Pract. A systematic review of enteral feeding by nasogastric tube in young people with eating disorders. the contents by NLM or the National Institutes of Health. Clinical adaptations/cohorts include variations on upper target (UL-9 with 9.0mmol/L, reducing workload and nutrition responsiveness), and insulin only (IO) with clinically set nutrition at 3 glucose concentrations (71g/L vs. 120 and 180g/L in the TARGET study). Studies published in languages other than English were translated prior to being reviewed. Nutr Clin Prac. These changes determine a further depletion of the mineral and vitamin pool (with depletion of ATP), a decrease in urinary sodium and water excretion, and a rapid fluid overload that can lead to congestive cardiac failure, respiratory failure, and impairment in many physiological processes up to death [4,6].
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