Use of High Protein Feeds in Refeeding Syndrome Adolescents with severe restrictive eating disorders often require enteral feeding to provide lifesaving treatment. Available literature suggests the following interventions may be reasonable: Want to Download the Episode?Right Click Here and Choose Save-As. Gusella and colleagues [41] compared parent led therapy (PLT) to non-specific therapy (psychologist led talking therapy). 1. PubMed Phosphate, an electrolyte that helps your cells convert glucose into energy, is often affected. See, treatment of established refeeding syndrome, Treatment of established refeeding syndrome, https://traffic.libsyn.com/secure/ibccpodcast/IBCC_EP_83_-_Refeeding_Syndrome.mp3. Three studies reported weight gain in the context of inadequate oral intake [9, 18, 39]. Refeeding Syndrome Guideline The real growth opportunity is guaranteed by the reimbursement. Rizo S, Douglas JW, Lawrence JC. The most common primary disease was cancer (n=267), followed by mesenteric ischemia (n=104), and surgical complications (n=62). 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. Before Street K, Costelloe S, Wooton M, Upton S, Brough J. In the circumstances that their BMI is detrimentally low, a nasogastric (NG) tube may be placed from nose to stomach to pass nutrition. Nutr Clin Prac. The incidence of RFS varied from 0% to 62% across the studies. 58% of the studies included only examined the effect of NG feeding as a secondary outcome of their study. BMJ Open. Int J Adolesc Med Health. Kezelman S, Crosby RD, Rhodes P, Hunt C, Anderson G, Clarke S, et al. This systematic review sets out to describe current practice of NG in young people with eating disorders. Robb AS, Silber TJ, Orwell-Valente JK, et al. https://doi.org/10.1093/pch/pxx063. between 7.8% and 23.4% (minimal and maximal error), and GNG at day 10 (age, mean and basal blood glucose), with an e.c. Most patients (96%) however present less severely with serum hypophosphataemia and no clinical signs [19]. GNG at day 4 and EGP at day 10 could not be predicted with an e.c. Search strategies combined keywords with controlled vocabulary terms (MeSH, Thesaurus); both quantitative and qualitative research were included. This is unknown. https://doi.org/10.1002/eat.20164. The flowchart relative to the selection process is reported in Fig. Leeds and York Partnership NHS Foundation Trust, Mill Lodge, 520 Huntington Rd, York, YO32 9QA, UK, You can also search for this author in Increase of parenteral nutrition intake (in % kcal of predicted resting energy expenditure) decreased phosphate concentrations (c=0.002 (95% CI -0.002;0.001). 3729-3740, Clinical Nutrition, Volume 40, Issue 6, 2021, pp. Child and adolescent mental health service, Preferred Reporting Items for Systematic Reviews and Meta-Analyses, National Guideline Alliance (UK). The correlation between EGP and GNG and 83 potential clinical indicators were explored, using single-stage and multivariate analysis. Monitor electrolytes carefully. British Dietetic Association. Refeeding Syndrome Guideline The findings of this systematic review suggested that specific subgroups of population, such as inpatients from ICU and those initially supplied with higher caloric intakes, might have an increased risk for RFS/RH, but robust evidence is still lacking. Web[34][35][36] Multiple studies apply or recommend the classification of refeeding risk according to the NICE criteria. In most studies the NG feed supplemented any deficit in oral intake but occasionally also provided additional calories above those prescribed in the oral meal plan [22, 25, 39]. Patients at risk for refeeding syndrome should be treated in the hospital setting due to the need for frequent laboratory monitoring. Identifying the associations between plasma SCFA levels and intronic DNA methylation of HIF3A may reveal useful predictors or provide insights into the disease processes of DCM. Treatment of patients with eating disorders. People who are at risk of heart-related complications may require heart monitoring. https://doi.org/10.1017/S0033291714001573. Consequently, poor muscle status, determined by CT imaging, does not justify denying a patient an oncologic resection. We avoid using tertiary references. Further research is required to assess which method is the safest, most efficacious and best aids transition back to a fully oral diet. https://doi.org/10.1177/0148607106030003231. The DOI: Lambers WM, et al. Enteral nutrition via nasogastric tube for refeeding patients with anorexia nervosa: a systematic review. Low baseline levels of K/Phos/Mg. Clausen [46] described NG as the most frequently used involuntary measure in psychiatric practice and is most commonly used in 1517year olds. Refeeding syndrome is a serious and potentially fatal condition that can occur during refeeding. Paediatr Child Health. Phone: 866.485.6911, 2020 ACUTE Center for Eating Disorders & Severe Malnutrition by Denver Health. https://doi.org/10.1002/eat.22968. 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. 08-E012. 31 While ongoing alcohol use will place individuals at risk for ongoing phosphorus loss, abnormalities in the excretion of urinary phosphate typically resolves after a few weeks of ongoing abstinence. AHRQ publication no. Fuller S, Street O, Hudson L, Nicholls D. Enteral feeding young people with anorexia nervosa under restraint in inpatient settings. Whether sarcopenia worsens the outcome after esophagectomy is unclear. (2015). 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]. Int J Eat Disord. Hypophosphatemia is a common feature of refeeding syndrome. 73 (12.04%) were successfully weaned off PN. Certain conditions may increase your risk for this condition, including anorexia, alcohol use disorder, and more. All articles analysed in this study can be found in Table 1 and can be traced back to primary articles using References on Page 16. < 40%. Introduction | Nutrition support for adults: oral nutrition NOTE: Only 44% (8/19) of doctors compared with 70% (49/70) of dietitians followed the guidance. 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: What it is, and how to prevent and treat it. This guideline covers identifying and caring for adults who are malnourished or at risk of malnutrition in hospital or in their own home or a care home. 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. Nutr Dietetics. One study reported on weight gain where NG is routinely started on all ED YP regardless of context [23]. Start thiamine prophylactically (e.g., thiamine 100-200 mg IV q12-q24hr). NG feeding is a safe and efficacious method of increasing total calorie intake by either supplementing oral intake or continuously. Eur Eating Disord Rev. 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. PubMedGoogle Scholar. of 18.5% and 29.9%. https://doi.org/10.1155/2016/5168978. WebRefeeding syndrome is defined as the potentially fatal shifts in fluids and electrolytes that may. The primary physiologic problems are deficiencies of thiamine, phosphate, magnesium, and potassium (especially phosphate). Nehring I, Kewitz K, Von Kries R, Thyen U. Risk of refeeding was correctly identified and NICE guidelines were adhered to with commencement of feeding at 5kcal/kg/day and appropriate replacement of thiamine and complex vitamin B. 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]. Background The incidence of refeeding syndrome (RFS) in critically ill patients is high, which is detrimental to their prognoses. 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. However, there is no high-quality evidence that this reduces the risk of refeeding syndrome. Kristen Hindley. A total of 1247 patients were eligible (618 early-PN, 629 late-PN). Burden of eating disorders in 5-13-year-old children in Australia. 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. The duration of underfeeding is typically >7-10 days. It includes gluconeogenesis (GNG) from non-carbohydrate substrates and hepatic glycogenolysis. 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. https://doi.org/10.1002/1098-108X(200012)28:4<470::AID-EAT18>3.0.CO;2-1. Glycaemic control (GC) may improve outcomes, though safe and effective control has proven elusive. (2001). Maginot TR, Kumar MM, Shiels J, Kaya W, Rhee KE. Its caused by sudden shifts in the electrolytes that help your Refeeding Van Noort BM, Lohmar SK, Pfeiffer E, Lehmkul U, Winter SM, Kappel V. Clinical characteristics of early onset anorexia nervosa. Neither of these guidelines are specific for children and adolescents. 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. But this treatment may not be suitable for people with: In addition, fluids are reintroduced at a slower rate. Regulation of endogenous glucose production (EGP) is essential for glucose homeostasis. 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. 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. Between admission and discharge, Parker et al [24] reported a mean overall weight gain of 7.4kgs, Kezelman 2018 [26] reported a mean overall increase of 3.04kg/m2 BMI; Madden et al [25] reported a mean weight gain of 2.79 kgs during medical instability using continuous NG feeding at 2400 kcals per day. The optimal cutoff is unclear, possibly an absolute serum phosphate level below ~1.5 mg/dL (0.5 mM). Many sources recommend starting conservatively (e.g., 50% energy requirement), with gradual advancement. 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, 2017;5(1):110. The reintroduction of enteral or parenteral nutrition, leading to refeeding hypophosphatemia (RFH), has been presented as potential risk factor. 1). Serum phosphorus was measured on days 1, 3 and 7 post admission. Significant discrepancy (>700 calories) was noted between nurse-estimated caloric intake compared to digital images. The site is secure. This study aids the understanding of clinical nutrition strategies to prevent and treat refeeding syndrome. The inclusion criteria were: NG feeding, participants under 18years, eating disorders, published since 2000 and primary research. Attitudes to NICE guidance on refeeding syndrome 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]. The incidence rate of both RFS and RH greatly varied according to the definition used and the population analyzed, being higher in ICU inpatients and in those with increased initial caloric supply. Copyright 2023 Elsevier B.V. or its licensors or contributors. Bri J Mental Health Nursing. Side effects are minimal but may include nasal bleeding or irritation, and imbalances in blood electrolytes which can be reduced by providing supplementation. 2019. The novel associations between plasma butyric acid levels and HIF3A intron 1 methylation at CpG 6 may highlight an underlying mechanism by which the microbial-myocardial axis and hostmicrobe interactions may participate in the pathogenesis of DCM. Anorexia nervosa, anxiety, and the clinical implications of rapid refeeding. Conversely, in MH wards, if NG has to be given under restraint, it may be required for a significant duration; in one study [46] the average was 170days. Nutritional rehabilitation is central to achieving medical stabilization. NICE clinical guideline 32 (2006) criteria for recognising patients Royal Australian and new Zealand College of Psychiatrists clinical practice guidelines for the treatment of eating disorders. Treatment usually involves replacing essential electrolytes and slowing down the refeeding process. Patients at high risk of the syndrome may also be at risk of acute renal failure, which may be missed as they have only slightly raised urea and creatinine measurements because of low muscle mass, leading to low production of these metabolites. Extended period NPO (>5 days). 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. 2019;115(12):501. Halse C, Broughtwood D, Clarke S, Honey A, Kohn M, Madden S. Illumating multiple perspectives: meaning of nasogastric feeding in anorexia nervosa. Refeeding syndrome is a severe complication of refeeding in people with malnutrition, it includes a series of electrolyte disorders and clinical symptoms. Electrolyte levels are monitored with frequent blood tests. 2019;8(3):1248. Refeeding syndrome can affect anyone. The importance of the refeeding syndrome. 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). Refeeding syndrome: Problems with definition and management. People who are malnourished are at risk. Conversely any hospital admission was significantly longer (P<0.0001) for a YP requiring NG feeding compared to those managing an oral diet in a German retrospective cohort study [37]. According to these guidelines, patients at the highest risk for refeeding syndrome meet one or more of the following criteria: Body mass index (BMI) under 16; Weight loss of more than 15 percent of his or her body weight in the past 3 to 6 months; Little to no food for the past 10 or more consecutive days; or It comes after a rigorous review process. 3787-3792, Clinical Nutrition, Volume 40, Issue 6, 2021, pp. Nutrition (30) 1448-1455 There was a wide variety in length of time receiving NG for medical instability. 2011;19:52630. Consequently, the reported incidence rates varied between 0% and 80% depending on the definition and the population studied [2,8]. 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 Whenever possible, attempt to provide the. Inconsistent study results are partly caused by varying cut-off values used for defining sarcopenia. Couturier J, Mahmood A. 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. 1. Its caused by sudden shifts in the electrolytes that help your body metabolize food. How to Gain Weight Fast: Tips to Be Safe and Healthy, Diabulimia: Why This Eating Disorder Is So Dangerous for People with Diabetes. In the UK, three studies described NG use during medical instability after oral intake was refused [27, 28, 40] and one where oral intake was inadequate [31]. Young people with eating disorders often restrict food intake to a degree which is detrimental to their physical health. Complications that require immediate intervention can appear suddenly. Available from: https://www.ncbi.nlm.nih.gov/books/NBK436876/.