Higher Caloric Refeeding Is Safe in Hospitalised Adolescent Patients with Restrictive Eating Disorders (original) (raw)
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Journal of the Academy of Nutrition and Dietetics, 2018
Background Patients with eating disorders (EDs) are often considered a high-risk population to refeed. Current research advises using "start low, go slow" refeeding methods (w1,000 kcal/day, advancing w500 kcal/day every 3 to 4 days) in adult patients with severe EDs to prevent the development of refeeding syndrome (RFS), typically characterized by decreases in serum electrolyte levels and fluid shifts. Objective To compare the incidence of RFS and related outcomes using a low-calorie protocol (LC) (1,000 kcal) or a higher-calorie protocol (HC) (1,500 kcal) in medically compromised adult patients with EDs. Design This was a retrospective pre-testepost-test study. Participants/setting One hundred and nineteen participants with EDs, medically admitted to a tertiary hospital in Brisbane, Australia, between December 2010 and January 2017, were included (LC: n¼26, HC: n¼93). The HC refeeding protocol was implemented in September 2013. RESEARCH SNAPSHOT Research Question: Do medically compromised adult patients with eating disorders experience higher rates of refeeding syndrome when commenced on a higher-calorie protocol (1,500 kcal/day) than those commenced on a protocol with current recommended feed rates (1,000 kcal/ day)? Key Findings: One hundred nineteen participants were included in this observational study. No significant differences were found in the incidence of refeeding syndrome, electrolyte disturbances, or edema. No cases of refeeding syndrome were observed in either group.
Journal of Adolescent Health
Current refeeding recommendations for adolescents hospitalized with anorexia nervosa (AN) are conservative, starting with low calories and advancing slowly to avoid refeeding syndrome. The purpose of this study was to examine weight change and clinical outcomes in hospitalized adolescents with AN on a recommended refeeding protocol.Adolescents aged 13.1–20.5 years were followed during hospitalization for AN. Weight, vital signs, electrolytes, and 24-hour fluid balance were measured daily. Percent median body mass index (%MBMI) was calculated as 50th percentile BMI for age and gender. Calories were prescribed on admission and were increased every other day.Thirty-five subjects with a mean (SD) age of 16.2 (1.9) years participated over 16.7 (6.4) days. Calories increased from 1,205 (289) to 2,668 (387). No subjects had refeeding syndrome; 20% had low serum phosphorus. Percent MBMI increased from 80.1 (11.5) to 84.5 (9.6); overall gain was 2.10 (1.98) kg. However, 83% of subjects initially lost weight. Mean %MBMI did not increase significantly until day 8. Higher calories prescribed at baseline were significantly associated with faster weight gain (p = .003) and shorter hospital stay (p = .030) in multivariate regression models adjusted for %MBMI and lowest heart rate on admission.Hospitalized adolescents with AN demonstrated initial weight loss and slow weight gain on a recommended refeeding protocol. Higher calorie diets instituted at admission predicted faster weight gain and shorter hospital stay. These findings support the development of more aggressive feeding strategies in adolescents hospitalized with AN. Further research is needed to identify caloric and supplementation regimens to maximize weight gain safely while avoiding refeeding syndrome.
Journal of eating disorders, 2017
Current guidelines for nutritional rehabilitation in hospitalized restrictive eating disorder patients recommend a cautious approach to refeeding. Several studies suggest that higher calorie diets may be safe and effective, but have traditionally excluded severely malnourished patients. The goal of this study was to evaluate the safety of a higher calorie nutritional rehabilitation protocol (NRP) in a broad sample of inpatients with restrictive eating disorders, including those who were severely malnourished. A retrospective chart review was conducted among eating disorder inpatients between January 2015 and March 2016. Patients were started on a lower calorie diet (≤1500 kcals/day) or higher calorie diet (≥1500 kcals/day). Calorie prescription on admission was based on physician clinical judgement. The sample included patients aged 8-20 years with any DSM-5 restrictive eating disorder. Those who were severely malnourished (<75% expected body weight [EBW]) or required tube feedin...
Outcomes of a rapid refeeding protocol in Adolescent Anorexia Nervosa
Journal of eating disorders, 2015
The impact of severe malnutrition and medical instability in adolescent Anorexia Nervosa (AN) on immediate health and long-term development underscores the need for safe and efficient methods of refeeding. Current refeeding guidelines in AN advocate low initial caloric intake with slow increases in energy intake to avoid refeeding syndrome. This study demonstrates the potential for more rapid refeeding to promote initial weight recovery and correct medical instability in adolescent AN. Seventy-eight adolescents with AN (12-18 years), hospitalised in two specialist paediatric eating disorder units, for medical instability (bradycardia, hypotension, hypothermia, orthostatic instability and/or cardiac arrhythmia) were followed during a 2.5 week admission. Patients were refed using a standardised protocol commencing with 24-72 hours of continuous nasogastric feeds (ceased with daytime medical stability) and routine oral phosphate supplementation, followed by nocturnal feeds and a meal p...
BMJ Open, 2020
IntroductionProviding effective nutritional rehabilitation to patients hospitalised with anorexia nervosa (AN) is challenging, partly due to conservative recommendations that advocate feeding patients at low energy intakes. An ‘underfeeding syndrome’ can develop when patients are not provided with adequate nutrition during treatment, whereby malnourished patients fail to restore weight in a timely matter, and even lose weight. Of particular concern, the reintroduction of carbohydrate in a starved patient can increase the risk of developing electrolyte, metabolic and organ dysfunction. The proposed trial assesses the efficacy and safety of a lower carbohydrate enteral formula (28% carbohydrate) against a standard enteral formula (54% carbohydrate), in adolescent and young adult patients (aged 15–25 years), hospitalised with AN.Methods and analysisThe study employs a double-blind randomised controlled trial design. At admission to hospital, malnourished adolescent and young adults wit...
Journal of Eating Disorders, 2016
Background: Historically, inpatient protocols have adopted relatively conservative approaches to refeeding in Anorexia Nervosa (AN) in order to reduce the risk of refeeding syndrome, a potentially fatal constellation of symptoms. However, increasing evidence suggests that patients with AN can tolerate higher caloric prescriptions during treatment, which may result in prevention of initial weight loss, shorter hospital stays, and less exposure to the effects of severe malnutrition. Therefore the present study sought to examine the effectiveness of a more accelerated refeeding protocol in an inpatient AN and atypical AN sample. Methods: Participants were youth (ages 10-22) with AN (n = 113) and atypical AN (n = 16) who were hospitalized for medical stabilization. A retrospective chart review was conducted to assess changes in calories, weight status (percentage of median BMI, %mBMI), and indicators of refeeding syndrome, specifically hypophosphatemia, during hospitalization. Weight was assessed again approximately 4 weeks after discharge. Results: No cases of refeeding syndrome were observed, though 47.3 % of participants evidenced hypophosphatemia during treatment. Phosphorous levels were monitored in all participants, and 77.5 % were prescribed supplemental phosphorous at the time of discharge. Higher rates of caloric changes were predictive of greater changes in %mBMI during hospitalization. Rates of caloric and weight change were not related to an increased likelihood of re-admission. Conclusions: Results suggest that a more accelerated approach to inpatient refeeding in youth with AN and atypical AN can be safely implemented and is not associated with refeeding syndrome, provided there is close monitoring and correction of electrolytes. These findings suggest that this approach has the potential to decrease length of stay and burden associated with inpatient hospitalization, while supporting continued progress after hospitalization.
Outcomes of a higher calorie inpatient refeeding protocol in Asian adolescents with anorexia nervosa
International Journal of Eating Disorders, 2020
Objective: This study aims to compare the outcomes of higher calorie refeeding (HCR) and a lower calorie refeeding (LCR) methods among a diverse sample of young Asian adolescents admitted to a tertiary institution in Asia for management of anorexia nervosa (AN). Method: This is a retrospective case control study of Asian adolescents who were managed using an inpatient HCR protocol (2016-2017) and an LCR protocol (2010-2014). Baseline characteristics, daily change in percent median body mass index (%mBMI), and rates of refeeding hypophosphatemia were analyzed between groups. Results: A total of 125 adolescents with AN were analyzed with 61 (52%) patients in the HCR group. Mean age was 14.0 years (SD =1.5) and mean presenting %mBMI was 73.2 (SD =6.9) with mean length of stay of 11.9 days (SD = 6.6). Patients in the HCR group had significantly increased rate of change of %mBMI (M = 0.39, SD = 0.31) than patients in the LCR group (M = 0.12, SD = 0.43) (p < .001). There was an increased rate of mild hypophosphatemia in the HCR group (HCR: 46%, LCR: 22%, p = .007) but no difference in rates of moderate hypophosphatemia and no cases of severe hypophosphataemia. Lower presenting %mBMI significantly predicted the phosphate levels (p = .004). Discussion: In a sample of Asian adolescents with AN, use of an HCR protocol was associated with improved rate of inpatient weight gain. There was increased risk of mild hypophosphataemia, but not moderate to severe hypophosphataemia, suggesting that an HCR protocol can be used safely with close monitoring of phosphate levels.
2016
Anorexia nervosa (AN) is the most prevalent of eating disorders in children and adolescents, and its treatment is long and complex, involving a multidisciplinary team. Nutritional rehabilitation and restoration of a healthy body weight is one of the central goals in the initial stages of inpatient treatment. However, current recommendations on initial energy requirements for these patients are inconsistent, with a clear lack of controlled studies, available scientifi c evidence and global consensus on the most effective and safe refeeding practices in hospitalized adolescents with anorexia nervosa (AN). Conservative refeeding recommendations have been classically established in order to prevent the refeeding syndrome. Nevertheless, various works have recently appeared advocating a higher initial caloric intake, without observing more complications or refeeding syndrome, and allowing a shorter average stay. We present our experience in the treatment of restricting AN with a conservat...
2020
ObjectiveWeight restoration is an integral part of managing anorexia nervosa patients and has been found to be associated with electrolyte and fluid abnormalities gathered under the umbrella term refeeding syndrome, which has led to cautious initiation of caloric regimes. This study looks at how a sample of severe anorexia nervosa patients were managed using higher rates of refeeding than the ones currently recommended.Designretrospective cohort study of consecutive patients with severe eating disorders admitted to an UK specialist tertiary centre. The treatment programme uses a weight restoration regime starting at 1000 kcal/day, increased to 1500 kcal/day after two days and to 2000 kcal/day after seven days. The main outcome was the rate of hypophosphatemia, hypokalemia and hypomagnesemia within the first two weeks of weight restoration. The secondary outcomes included rate of weight gain and tendency of electrolyte shift.Results83% of the patient sample were categorised as extrem...