Other metabolic changes can also occur. Controlled studies of patients refeeding process with the outcome of length of stay were included. Risk of Refeeding Syndrome UHL Nutrition and This phenomenon is therefore also known as refeeding hypophosphatemia (RFH) [1517]. Furthermore, the incidence of refeeding hypophosphatemia (RH) was also assessed. Isner JM, Roberts WC, Heymsfield SB, Yager J. Anorexia nervosa and sudden death. 3729-3740, Clinical Nutrition, Volume 40, Issue 6, 2021, pp. WebRefeeding Syndrome NICE guidance (CG32) recommends that for people identified as being at high risk of developing refeeding syndrome, the following should be provided immediately before and during the first 10 days of reintroducing feeding only: oral thiamine 200-300 mg daily vitamin B compound strong 1 or 2 tablets, three times a Psychiatric nursing assistants views centred around: NG being an unpleasant practice, becoming sensitized or desensitized, and the importance of developing coping mechanisms to manage the distress. Pragmatic, prospective studies that control for this confounder are required for any such comparison to be made. The epigenetic regulation of the hypoxia-inducible factor 3A (HIF3A) gene is implicated in oxidative metabolism in the pathogenesis of diabetes. Consequently, poor muscle status, determined by CT imaging, does not justify denying a patient an oncologic resection. 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]. Significant discrepancy (>700 calories) was noted between nurse-estimated caloric intake compared to digital images. 69.) 2019;34(3):35970. Together, these processes can lead to decreased concentrations of minerals in the blood, of which hypophosphatemia is the most characteristic [14]. Two studies [37, 43], found NG feeding was more likely to be required in: patients of a lower age at admission (14.3years compared to 15.3yrs. The search criteria was peer reviewed by a researcher from the University of Yorks Child and Adolescent Mental Health Intervention Centre. WebRefeeding syndrome is defined as the potentially fatal shifts in fluids and electrolytes that may. In a recent systematic review [32] 9/10 studies in hospitalised ED patients are given continuous or overnight supplemental NG feeding. Advance diet gradually as tolerated. Moreover, refeeding syndrome is seems to be associated with increased 6 months mortality [15]. 2012;27:3440. See additional information. Online Medical Education on Emergency Department (ED) Critical Care, Trauma, and Resuscitation. (2004). 2020;34:3341. 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]. However, there is no high-quality evidence that this reduces the risk of refeeding syndrome. Refeeding Syndrome: Definition, Treatment, Risks, and More https://doi.org/10.7748/ns.2017.e10509. Thirty-five observational studies were included in the analysis. 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. The average length of time on NG feeding in this study was 20.7days; NG was terminated as YP accepted more than 50% oral caloric quota compared to theoretical reported quota. Fuller S, Street O, Hudson L, Nicholls D. Enteral feeding young people with anorexia nervosa under restraint in inpatient settings. 3787-3792, Clinical Nutrition, Volume 40, Issue 6, 2021, pp. No substantial change in the originally reported incidence of RFS was found by applying the ASPEN criteria. 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]. It occurs in significantly malnourished patients when a diet of increasing calories is initiated orally, by nasogastric (NG) tube and/or delivered intravenously. 29002-0025.) Any discussion on the risks of the refeeding syndrome should include the increased threat of infection that may often be silent in malnutrition. statement and The importance of the refeeding syndrome. However, refeeding is also a critical component to recovery and NG feeding will often be utilised if a young person has been unable to manage oral intake in order to prevent signs of physical unwellness [9, 10]. 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]. Further research is warranted to determine whether refeeding syndrome prolongs the length of stay, and to verify the effect of different energy intakes during refeeding on the length of stay in people with malnutrition. Crook MA, et al. When individuals who are at risk are identified early, treatments are likely to succeed. 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. Am J Psychiatry. JAMA Pediatr; doi: 10.1001/jamapediatrics.2020.3359Investigators from multiple Overall, this review found 5 studies [9, 18, 23, 24, 29] reported some incidence of electrolyte disturbance, 2 studies [29, 39] described epistaxis and 1 study [39] described behavioural problems associated with the procedure. Does aggressive refeeding in hospitalized adolescents with anorexia nervosa result in increased hypophosphatemia? 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. More well-designed randomized controlled trials are needed to explore the effect of calorie intake during refeeding. The present study showed that the incidence of RFS is highly dependent on the definition used and the population analyzed, ranging from 0% up to 62%. A randomized controlled trial of in-patient treatment for anorexia nervosa in medically unstable adolescents. Patients randomized to late-PN had a lower chance of developing early RFH, which may be explained by the more gradual build-up of nutrition. The refeeding syndrome. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. Cite this article. NICE guidelines regarding refeeding syndrome, based on a very cautious refeeding regime reaching estimated calorie and protein needs within 7 days, compared Development and validation of risk prediction model for Conversely, Akgul and colleagues [36] described a much shorter average time, 2.5days, that YP required NG before transitioning to an oral diet. Nutritional glucose intake affects blood glucose (BG) outcomes, but few protocols actively control it. To keep this page small and fast, questions & discussion about this post can be found on another page here. sharing sensitive information, make sure youre on a federal BMJ Open. ;2020 2020 Predict the risk Obtain Caloric goal needs in 3-7 days Emad Zarief 2021 30 Editor's Notes CRRT Continuous R. R. therapy, ED emergency department Hypophosphatemia during critical illness has been associated with adverse outcome. 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. 2019;115(12):501. Results have shown that NG feeding is used commonly in the hospital setting to treat medical instability as a result of severe malnourishment, and in the specialist eating disorders (ED) unit due to failure to meet oral intake. There is a need for more high quality data in when to initiate NG, comparing different methods of delivering NG feeds and transitioning from NG to oral diet in YP with restrictive ED to enable future direction for clinicians. Reduce the caloric intake to 20 kCal/hr for at least two days. Neiderman M, Zarody M, Tattersall M, Lask B. Enteric feeding in severe adolescent anorexia nervosa: a report of four cases. Available literature suggests the following interventions may be reasonable: Want to Download the Episode?Right Click Here and Choose Save-As. Guidance A history of alcoholism or misuse of certain drugs, such as insulin, chemotherapy drugs, diuretics or antacids. https://doi.org/10.1515/ijamh-2014-0078. Hindley, K., Fenton, C. & McIntosh, J. 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. However, this will be the first systematic review on the use of NG feeding specifically in YP with ED. 2018;51(11):121322. J Eat Disord. Cells need electrolytes like phosphate to convert glucose to energy, but phosphate is in short supply. ASPEN Consensus Recommendations for Refeeding As a result, prevention is critical. Nurs Times. All rights reserved. A secondary care hospital in rural India serving a highly tuberculosis (TB) and malnutrition endemic region. Unfortunately, owing to the high heterogeneity of data, summary incidence measures are meaningless. A systematic review of approaches to refeeding in patients with anorexia nervosa. 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 Int J Eat Disord. WebRefeedingSyndromeDefinitionandBackground. Twenty-nine studies met the full criteria. Extended period NPO (>5 days). A number of YP in MH wards required restraint to NG feed with one study reporting this was required for 66% of YP [24]. Refeeding with a lower calorie provision and a slow energy increase may be a better approach for severely malnourished patients with chronic comorbidity, while higher caloric intakes might be reserved for moderately malnourished patients with acute illnesses [ 69 ]. Birmingham CL, Su J, Hlynsky JA, Goldberg EM, GAO M. The mortality rate from anorexia nervosa. Copyright 2023 Elsevier B.V. or its licensors or contributors. Changes in these symptoms were not attributed to the rate of weight restoration suggesting a rapid refeeding schedule would not exacerbate psychiatric symptoms. Here are the 12 best vegan protein powders. 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. Predictive factors of length of inpatient treatment in anorexia nervosa. Valentina Ponzo: Data curation, Writing - Review & Editing. The reintroduction of enteral or parenteral nutrition, leading to refeeding hypophosphatemia (RFH), has been presented as potential risk factor. Webreport, literature review and clinical guidelines. Preventative therapies: Thiamine 100-200 mg q12-24. From hospital unit to intestinal failure center: Twenty years of history, The goldilocks problem: Nutrition and its impact on glycaemic control. It is not possible from this review to discern the advantages and disadvantages of each method as no study made a direct comparison. If phosphate falls <1.5 mg/dL (0.5 mM) this indicates refeeding syndrome > see treatment below. Most studies tailored the calorie requirements to the individual patient, accounting for initial weight for height percentage and signs of medical instability. Refeeding is the process of reintroducing food after malnourishment or starvation. 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). Nutritional Assessment - BAPEN 2018;26(5):51925. Exclusion terms: psychiatric disorders other than eating disorders; non-primary research; no outcomes specific to NG feeding and participants over 18years. Nehring I, Kewitz K, Von Kries R, Thyen U. Some studies have demonstrated that the bioavailability of oral thiamine is substantial. Search strategies combined keywords with controlled vocabulary terms (MeSH, Thesaurus); both quantitative and qualitative research were included. From this systematic review 3 methods of NG feeding in YP with ED were found: continuous [23, 25], nocturnal [26, 29], and bolus meal replacement [9]. Rhabdomyolysis can occur (causing an elevated creatinine kinase). Refeeding syndrome is a potentially fatal complication which generally occurs within 24-72 hours after starting nutrition (although it may occur later on). Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. 2016;58(6):6419. Certain conditions may increase your risk for this condition, including anorexia, alcohol use disorder, and more. A Systematic Review of the Role of Thiamine The evolution of all aspects of HPN is presented. Madden S, Morris A, Zurynski YA, Kohn M, Elliot EJ. Youve lost more than 10 percent of your body weight in the past 3 to 6 months. Electrolyte levels are monitored with frequent blood tests. https://doi.org/10.1016/j.jadohealth.2013.06.005. 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. Globally studies from North America [18, 21, 39, 41] and Turkey [36] focused on medical instability in YP with ED. 2019;24(2):17998. https://doi.org/10.1002/ncp.10187. Background. All authors assessed bias risk. 2015;45(2):41527. The correlation between EGP and GNG and 83 potential clinical indicators were explored, using single-stage and multivariate analysis. Article However, this study does not discuss the reasons NG was implemented. Previous systematic reviews [2,8] showed that studies on RFS were highly heterogenous since most definitions were based on blood electrolyte disturbances, mainly refeeding hypophosphatemia (RH), while others considered the presence of overt signs and symptoms as well (i.e., edema, respiratory or heart failure). These include: Refeeding syndrome can cause sudden and fatal complications. Increase of parenteral nutrition intake (in % kcal of predicted resting energy expenditure) decreased phosphate concentrations (c=0.002 (95% CI -0.002;0.001). 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. Only 44% (8/19) of doctors compared with 70% (49/70) of dietitians followed the guidance. All rights reserved. https://doi.org/10.1186/s40337-016-0132-0. The majority commenced on daily intake of less than 2000kcal and increased periodically. 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]. Kodua M, MacKenzie JM, Smyth N. Nursing assistants experiences of administering manual restraint for compulsory nasogastric feeding of young persons with anorexia nervosa. Hay AP, Chinn D, Forbes D, Madden S, Newton R, et al. None developed clinical RFS. Refeeding syndrome is a severe complication of refeeding in people with malnutrition, it includes a series of electrolyte disorders and clinical symptoms. Front Psychol. 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], [2], [3]].