Its caused by sudden shifts in the electrolytes that help your body metabolize food. Aggressive repletion of electrolytes, with the exception of calcium (IV calcium may exacerbate hypophosphatemia). Check electrolytes (including magnesium and phosphate), with aggressive repletion as needed. 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. For nocturnal feeds, oral diet was encouraged during the day. Plasma butyric acid levels and HIF3A mRNA expression in peripheral blood were decreased in DCM patients, whereas 3 CpGs in HIF3A intron 1 (CpG 6, CpG 7 and CpG 11) were highly methylated in DCM patients. Refeeding syndrome awareness, prevention, and management. Skeletal muscle index (SMI), quantifying muscle mass, was assessed with computed tomography (CT) in 98 patients undergoing esophagectomy. Enteral nutrition via nasogastric tube for refeeding patients with anorexia nervosa: a systematic review. To keep this page small and fast, questions & discussion about this post can be found on another page here. J Dev Behav Pediatr. This review describes the large differences in the use of NG for YP with ED in medical and psychiatric wards in a number of countries globally. Recent guidance from the British Dietetic Association [14] for NG feeding under restraint advised 12 bolus feeds per day even in those with high risk of refeeding syndrome (RS); it also concluded further research into this area was required. 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. In this study conducted on patients with chronic protein energy malnutrition (PEM) and TB, we sought to compare nurse-estimated vs. smartphone photograph analytic methods for assessing caloric intake and determine the incidence of refeeding hypophosphatemia (RH) and refeeding syndrome (RFS) in patients with TB. Med J Aust. Kezelman and colleagues (Australia) 2018 [26] assessed the impact on anxiety, depression and ED symptoms when using NG in adjunct to oral intake as part of a rapid refeeding regime. Iolanda Cioffi: Conceptualization, Data curation, Methodology, Writing- Original draft preparation, Writing - Review & Editing. WebIf the patient is considered to be at high risk of refeeding syndrome, the following steps are advised by NICE:1 Start nutrition support at a maximum of 10 kcal/kg/day, increasing levels slowly to meet or exceed full needs by four to seven days. No ethical approval or consent to participate required due to the nature of the study. A comprehensive database search of AMED, EMBASE, APA Psychinfo and MEDLINE was performed with no language restriction from January 2000 to July 2020. In the circumstances that their BMI is detrimentally low, a nasogastric (NG) tube may be placed from nose to stomach to pass nutrition. As early RFH might impact recovery, it is important to closely monitor phosphate concentrations in patients, especially of those at risk for early RFH. Underweight or recent weight loss. 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. Hay AP, Chinn D, Forbes D, Madden S, Newton R, et al. 2017;31(45):427. Start vitamin B12 (cyanocobalamin) 1,000 micrograms PO daily. Effect sizes were expressed as 95% confidence intervals (CIs) and calculated using random-effects models. Two studies examined therapeutic interventions to reduce the need for NG or length of time on it in medically stable YP [29, 41]. Patients with renal replacement therapy or unavailable phosphate concentrations were excluded from this analysis. Titles and abstracts were screened by all authors before reviewing full length articles. As such, this might be most accurately termed carbohydrate refeeding syndrome.. Nurs Times. One article published prior to 2000 was included in the full text review due to it requiring translation prior to assessing it against the criteria. Treatment of patients with eating disorders. Young people with eating disorders often restrict food intake to a degree which is detrimental to their physical health. All rights reserved. Does aggressive refeeding in hospitalized adolescents with anorexia nervosa result in increased hypophosphatemia? Bethesda, MD 20894, Web Policies The incidence of RFS varied from 0% to 62% across the studies. The pooled effect of higher calorie intake of 1234 patients in 8 studies was WMD=3.04 (95% CI,5.10 to0.99, P=0.003) days. Perhaps carbohydrates should initially be limited to <40% of the total energy intake. Many sources recommend starting conservatively (e.g., 50% energy requirement), with gradual advancement. 2019. https://doi.org/10.1007/s40519-018-0572-4. WebBACKGROUND. Key studies were manually reviewed for additional research, but none were identified that were not already included, 1 eligible study was identified through peer review. The duration of underfeeding is typically >7-10 days. The outcomes of interest were: Opinions of YP and staff using NG, amount of YP requiring NG, any interventions that impacted on NG feeding, complications of NG feeding, interventions to mitigate the complications, the setting (medical ward, psychiatric ward or outpatient), the NG method and whether this changed when restraint was required. All authors have reviewed the document and consent to publication. It should be recognized that refeeding syndrome can occur among stressed ICU patients if nutrition is interrupted for only a short period of time (e.g., one week). 1985;102(1):4952. 85% were at risk of RFS by National Institute for Health and Care Excellence (NICE) criteria. 1 Malnourished Neiderman et al [40] qualitative study describes patients time receiving NG varying from 1 to 476days (methods not explained). J Nutr Metab. https://doi.org/10.1186/s40337-016-0132-0. ScienceDirect is a registered trademark of Elsevier B.V. ScienceDirect is a registered trademark of Elsevier B.V. 2022, Journal of Parenteral and Enteral Nutrition, Clinical Nutrition, Volume 40, Issue 6, 2021, pp. They concluded that the requirement for NG was an indication of severity and resistance to oral feeding [44]. NICE guidelines regarding refeeding syndrome, based on a very cautious refeeding regime reaching estimated calorie and protein needs within 7 days, compared Rhabdomyolysis can occur (causing an elevated creatinine kinase). WebThese consensus recommendations are intended to provide guidance regarding recognizing risk and identifying, stratifying, avoiding and managing RS. Furthermore, the incidence of refeeding hypophosphatemia (RH) was also assessed. They are at even greater risk of precipitate falls in these circulating electrolytes once simultaneous nutritional and fluid therapy has started. Int J Eat Disord. 2018;51(11):121322. The decrease of nutritional status has affected one-third hospitalized patients, while there is no widely used definition of malnutrition. Refeeding syndrome: A literature review. DOI: Mehanna HM, et al. Patients with restrictive eating disorders, including anorexia nervosa (AN), bulimia nervosa (BN) and eating disorder not otherwise specified (EDNOS), are predominantly female (91%) and Caucasian (92%), with incidence being approximately 0.014 for females [3]. A systematic review of enteral feeding by nasogastric tube in young people with eating disorders. It offered the unique chance to present how to create and grow the IF center, increasing the quality of care. All rights reserved. The potential risk of refeeding syndrome should be considered whenever starting any previously underfed patient on nutrition. The most common symptoms are as follows: Unfortunately, there is no uniform definition of refeeding syndrome. 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. Phone: 866.485.6911, 2020 ACUTE Center for Eating Disorders & Severe Malnutrition by Denver Health. The repletion of calories should be slow and is typically at about 20 calories per kilogram of body weight on average, or around 1,000 calories per day initially. In 2018, the ACUTE Center for Eating Disorders & Severe Malnutrition at Denver Health was honored by Anthem Health as a Center of Excellence for Medical Treatment of Severe and Extreme Eating Disorders. 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. Retrospective cohort analysis of 5 glycaemic control cohorts spanning 4 years (n=273) from Christchurch Hospital Intensive Care Unit (ICU). The above became the aim of this study. Anorexia nervosa, anxiety, and the clinical implications of rapid refeeding. Results demonstrated that YP receiving PLT had a significantly reduced requirement for NG (P<0.05). The Charlson Comorbidity Index, however, was superior for preoperative risk stratification. Phosphate, an electrolyte that helps your cells convert glucose into energy, is often affected. 2018;9:P1097. 2 studies [21, 47] examined male only cohorts but both were high risk of bias. Our results suggest that a robust model might be built, but requires a prospective study including a larger number of patients. There was no disagreement between CF and KH who assessed which studies were included. However, treatment providers should regularly monitor at-risk patients for symptoms of refeeding syndrome. Conversely, Akgul and colleagues [36] described a much shorter average time, 2.5days, that YP required NG before transitioning to an oral diet. In addition, the incidence of RH was also assessed since it is considered the hallmark of the syndrome. 69.) 1Southampton University Hospital NHS Trust, Southampton SO16 6YD, 2Royal Bournemouth Hospital, Bournemouth, Dorset BH7 7DW. Strik Lievers L, Curt F, Wallier J, Perdereau F, Rein Z, Jeammet P, et al. 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. There was a wide variety in length of time receiving NG for medical instability. RS is historically described as a range of metabolic and electrolyte alterations occurring as a result of the rein- troduction Copyright 2023 Elsevier B.V. or its licensors or contributors. https://doi.org/10.1038/ejcn.2013.244. Long-term effects of enteral feeding on growth and mental health in adolescents with anorexia nervosa--results of a retrospective German cohort study. Turk J Pediatr. How to Gain Weight Fast: Tips to Be Safe and Healthy, Diabulimia: Why This Eating Disorder Is So Dangerous for People with Diabetes. NICE. Naso-Gastric Tube Feeding under restraint best practice guidelines for Dietitians 2019. For example, insulin is a hormone that breaks down glucose (sugar) from carbohydrates. 2016;49(3):293310. Patients with RH underwent further evaluation for RFS-associated findings. 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. Garber AK, Sawyer SM, Golden NH, Guarda AS, Katzman DK, Kohn MR, et al. Restore circulatory volume and monitor fluid balance and overall clinical status closely. Best C. How to set up and administer an enteral feed via a nasogastric tube. Exclusion terms: psychiatric disorders other than eating disorders; non-primary research; no outcomes specific to NG feeding and participants over 18years. Cumulated insulin dose between days 5 and 9 was correlated to EGP at day 10 (R=0.55, P=0.03). Nutritional glucose intake affects blood glucose (BG) outcomes, but few protocols actively control it. Figure1 displaying PRISMA flowchart of methodology utilised to search databases for this systematic review of enteral feeding in young people with restrictive eating disorders. Last medically reviewed on January 6, 2020. Although there are some RCTs examining aspects of NG use in YP with ED the majority of studies were retrospective cohorts or case series. Encephalitis. 314 patients (51.8%) died. 2014;68(2):1717. National Library of Medicine Clinical Nutrition (2002) 21 (6): 515-520. https://doi.org/10.1515/ijamh-2014-0078. B12, 1000 mcg PO However, this new definition may be insufficiently specific for clinically relevent electrolyte changes and requires clinical validation. 777 Bannock Street Andrea Evangelista: Formal analysis; Software. 2002;159(8):134753. 3729-3740, Clinical Nutrition, Volume 40, Issue 6, 2021, pp. Giovannino Ciccone: Visualization, Writing - Review & Editing, Supervision. It is not possible from these studies to make any comparison between NG feeding and oral intake due to the confounding effect that for the vast majority of studies only high risk, medically unstable YP were considered for NG feeding. Skrik Liever et al [44] reported 27% required NG feeding and linked this to a faster weight gain but gave no information related to NG feeding protocols. Intravenous (IV) infusions based on body weight are often used to replace electrolytes. Google Scholar. Studies using bolus feeds stated that oral intake was encouraged and it was only when this was not fully achieved that supplementary NG was used [39]. California Privacy Statement, Permissive hyperglycemia could be safer than the administration of high doses of insulin. London: National Institute for Health and Care Excellence (UK); 2017. Kwashiorkor and marasmus are forms of undernutrition. We avoid using tertiary references. 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]. Similar to the review conducted by Hale and Logomarsino [33] who found RS to be a rare complication, it is reassuring to find that no study in this review reported YP developing RS despite some studies starting on high calorie NG feeding plans [9, 18, 24, 42]. This could have the advantage of reducing LOS in medically stable YP. A broader view of electrolyte shifts may be a welcome addition, given that prior definitions have focused excessively on phosphate. This study aids the understanding of clinical nutrition strategies to prevent and treat refeeding syndrome. Youve taken in little to no food for the past 5 or more consecutive days. Crook MA, et al. encourage healthy eating and reaching a healthy body weight cover nutrition, cognitive restructuring, mood regulation, social skills, body image concern, self-esteem, and relapse prevention create a personalised treatment plan based on the processes that appear to be maintaining the eating problem specialist registrar gastroenterology and clinical nutrition. 3677-3687, Clinical Nutrition, Volume 40, Issue 6, 2021, pp. A systematic review following PRISMA guidelines was conducted by searching AMED, EMBASE and MEDLINE databases from 2000 to 2020. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. (2016). Rockville: Agency for Healthcare Research and Quality; 2008. This difference could account for the divergent outcomes from studies on the impact NG has on the LOS between medical and psychiatric settings [23, 44]. 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]. Webreport, literature review and clinical guidelines. Parker E, Faruquie S, Anderson G, et al. volume9, Articlenumber:90 (2021) Results imply modulation of nutrition alongside insulin improves GC, particularly in patients with persistent hyperglycaemia/low glucose tolerance. Rocks T, Pelly F, Wilkinson P. Nutritional management of anorexia nervosa in children and adolescent inpatients: the current practice of Australian dietitians. https://doi.org/10.1002/eat.1040. Further research is required to assess which method is the safest, most efficacious and best aids transition back to a fully oral diet. In April 2020, the American Society for Parenteral and Enteral Nutrition (ASPEN) published a consensus recommendation for screening, diagnosis, and treatment of the RFS [1]. London: National Institute for a Clinical Excellence; 2004. Overall, these manifestations are variable and insensitive tools for detecting refeeding syndrome. 2014;48(11):9771008. Thiamine (e.g., 500 mg IV q8hr, if mental status changes). Home parenteral nutrition (HPN) is one of the most demanding medical therapies as it is the only option for patients for intestinal failure (IF). The correlation between EGP and GNG and 83 potential clinical indicators were explored, using single-stage and multivariate analysis. 2023 Healthline Media LLC. Am J Psychiatry. Youve lost more than 10 percent of your body weight in the past 3 to 6 months. But this treatment may not be suitable for people with: In addition, fluids are reintroduced at a slower rate. However, it typically follows a period of: Certain conditions may increase your risk for this condition, including: Certain surgeries may also increase your risk. Core interventions in the treatment and management of anorexia Nervosa bulimia Nervosa and related eating disorders. A major cause of refeeding syndrome seems to be an endogenous insulin surge, which is triggered by carbohydrate intake. The Refeeding Syndrome (RFS) is a potentially serious, but still overlooked condition, occurring in individuals who are rapidly fed after a period of severe 2012;27:3440. Though some people who are at risk dont develop symptoms, theres no way to know who will develop symptoms before beginning treatment. Although complications such as electrolyte abnormalities did occur there was no evidence that this was attributable to the NG feeding compared to oral diet [9, 18, 23, 24]. All authors assessed bias risk. Length of stay was reported in studies from medical and MH ward settings, however, the specific package of treatment YP received in each study was different depending on the country of origin. The reintroduction of enteral or parenteral nutrition, leading to refeeding hypophosphatemia (RFH), has been presented as potential risk factor. The refeeding syndrome. Refeeding syndrome results from underfeeding for a period of time, followed by re-initiation of nutritional support (including enteral nutrition, parenteral nutrition, or even IV dextrose). Gusella and colleagues [41] compared parent led therapy (PLT) to non-specific therapy (psychologist led talking therapy). 2009;17(4):32732. RS can manifest as hypophosphatemia (HP), hypomagnesemia, hypokalemia and other electrolyte imbalances that result in cardiac arrhythmias, seizures and in some cases sudden death [18]. PubMed Central There are many vegan protein powders on the market, with a variety of flavors and ingredients available. Together, these processes can lead to decreased concentrations of minerals in the blood, of which hypophosphatemia is the most characteristic [14]. (2014). Refeeding protocols daily calorie intake varied greatly between studies particularly as many studies were evaluating the outcome of higher calorie refeeding protocols [9, 18, 22, 24, 31]. https://doi.org/10.7748/ns.2017.e10509. In addition, refeeding often occurs alongside other serious conditions that typically require simultaneous treatment. 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], 2011;19:52630. The optimal cutoff is unclear, possibly an absolute serum phosphate level below ~1.5 mg/dL (0.5 mM). 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. Accessibility WebNephrotic syndrome . Agostino H, Erdstein J, Di Meglio G. Shifting paradigms: continuous nasogastric feeding with high caloric intakes in anorexia nervosa. Early RFH occurred in 40 patients (3%) in total, significantly more in the early-PN group (n=31, within-group occurrence 5%) than in the late-PN-group (n=9, within-group occurrence 1%, p<0.001). People who are malnourished are at risk. occur in malnourished patients on refeeding following a period of starvation. Hindley, K., Fenton, C. & McIntosh, J. 8600 Rockville Pike Therefore, the present systematic review and meta-analyses aimed to estimate the incidence of RFS in adults by considering the definition used by the authors as well as the recent criteria proposed by the ASPEN consensus (when applicable). Available literature suggests the following interventions may be reasonable: Want to Download the Episode?Right Click Here and Choose Save-As. We use cookies to help provide and enhance our service and tailor content and ads. By continuing you agree to the use of cookies. Gradual initiation of nutrition for the highest risk patients. 2019. https://www.nice.org.uk/guidance/qs24. Although there is a significant body of research into this, the role of NG feeding remains ill-defined [17]. AustralasPsychiatry. 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. Provided by the Springer Nature SharedIt content-sharing initiative. Nehring and colleagues [37] concluded that NG feeding had no impact on growth, recovery or development of psychiatric co-morbidities.
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