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. This leads to another condition called hypophosphatemia (low phosphate). 2014;68(2):1717. Int J Eat Disord. Journal of Eating Disorders 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. In two studies intensive meal support and concurrent therapy reduced the number of NG episodes (in medically stable YP) before managing a full oral diet [29, 41]. CR168s Summary of Junior Marsipan: Management of really sick patients under 18 with Anorexia Nervosa. Patients at risk for refeeding syndrome should be treated in the hospital setting due to the need for frequent laboratory monitoring. The majority of studies included were retrospective and based around case note reviews which are subjective and therefore likely to be biased. The risk of bias was serious in 16 studies and moderate in the remaining 19. Although there are some RCTs examining aspects of NG use in YP with ED the majority of studies were retrospective cohorts or case series. The flowchart relative to the selection process is reported in Fig. Treatment of patients with eating disorders. https://doi.org/10.1155/2016/5168978. 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. Bri J Mental Health Nursing. Its caused by sudden shifts in the electrolytes that help your Careers, Unable to load your collection due to an error. 2005;38(2):1436. Nasogastric (NG) feeding use in YP with ED may be used as a lifesaving treatment when patients are physically unwell [7, 8]. The risk for developing refeeding syndrome correlates directly with the extent of weight loss that accompanies anorexia nervosa. https://doi.org/10.1515/ijamh-2014-0078. Crook MA, et al. PubMed, Embase, Cochrane Library, Web of Knowledge, and two Chinese databases were systematically searched until October 2021. Refeeding syndrome can affect anyone. Given that the procedure can be painful [48] for YP and cause complications [29, 39], there is an urgent need for research exploring this wide variation in use of NG feeding to enable future direction and best practice guidance clinicians. To analyze the relationship of lengths of stay to muscle parameters, the competing risk approach introduced by Fine and Gray was applied. 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. Previous studies indicate that the incidence of refeeding syndrome is relatively high [12], including electrolyte abnormalities with sodium-water retention, which may potentially lead to heart and respiratory failure, even death [11,13,14]. Int J Eat Disord. Family-based treatment (FBT) is a psychotherapy shown to be effective in a number of randomized controlled trials in physically stable patients with anorexia nervosa (AN), under the age of 19, and within 3 years of illness. Results interpreted from studies with a high risk of bias were removed accordingly, leaving only high quality results and conclusions. To keep this page small and fast, questions & discussion about this post can be found on another page here. This is unknown. None developed clinical RFS. Cells need electrolytes like phosphate to convert glucose to energy, but phosphate is in short supply. A new riskassessment model was developed; nevertheless, further validation Overall, 39% (57/146) of all responders thought the guidance represented safe practice, whereas 36% (53/146) thought they were excessively cautious. Denver, CO 80204 Fabrizio Pasanisi: Visualization, Writing - Review & Editing. Until a consensus definition is obtained, the following criteria seems reasonable: (29901461). Yet again, the incidence is Start vitamin B12 (cyanocobalamin) 1,000 micrograms PO daily. A retrospective analysis of all medical records of HPN patients from the University Hospital and Stanley Dudrick's Memorial Hospital in Skawina. 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]]. A secondary care hospital in rural India serving a highly tuberculosis (TB) and malnutrition endemic region. No study discussed in detail the strategy used to transition from NG feeds back to an oral diet. Refeeding syndrome is an important complication of refeeding in previously malnourished patients [11]. 3807-3814, Indian Journal of Tuberculosis, Volume 67, Issue 2, 2020, pp. But this treatment may not be suitable for people with: In addition, fluids are reintroduced at a slower rate. Effectiveness of assisted reproductive technology. https://doi.org/10.24953/turkjped.2016.06.010. Sodium (salt) replacement may also be carefully monitored. (2015). Treatment usually involves replacing essential electrolytes and slowing down the refeeding process. Univariate, unadjusted long-term survival analysis revealed that lower MRA and lower SMI were associated with shorter survival (P=0.03). 86% of studies were deemed high or medium risk of bias due to the type of study: 34.4% retrospective cohort and 10.3% RCT; 17.2% were qualitative. Similarly, the incidence of RH ranged between 7% and 62%. Nurse estimated caloric intake was compared with digital before and after meal images. Other factors can also put you at an increased risk of developing refeeding syndrome. Whenever possible, attempt to provide the. A blood test that reveals low levels of phosphorus, potassium or magnesium. Iolanda Cioffi: Conceptualization, Data curation, Methodology, Writing- Original draft preparation, Writing - Review & Editing. You can learn more about how we ensure our content is accurate and current by reading our. More on how to calculate tube feeding rates here: Insulin appears to play a central role in the generation of refeeding syndrome. Psychol Med. 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]. In the present review, we concluded that higher initial calorie intake may help shorten the length of stay in patients with malnutrition. No ethical approval or consent to participate required due to the nature of the study. An essential first step in acute treatment is nutritional rehabilitation (refeeding malnourished patients) and restoring a healthy body weight. 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. However, this will be the first systematic review on the use of NG feeding specifically in YP with ED. The other presented post RYGB with a BMI of 37kg/m[2]. J Adolesc Health. There are no other acknowledgements to be made. More well-designed randomized controlled trials are needed to explore the effect of calorie intake during refeeding. A team with experience in gastroenterology and dietetics should oversee treatment. 2021 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. Kwashiorkor and Marasmus: Whats the Difference? You might be at risk if you: Refeeding syndrome is a serious condition. 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. Eighteen studies involving 3868 participants were included in our review. https://doi.org/10.1002/eat.22968. Part of 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]. However, further research is required to assess the optimum NG feeding regime for YP at different levels of RS risk. Magnitude of gluconeogenesis and endogenous glucose production: are they predictable in clinical settings? 2015. Eur Eating Disord Rev. 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. 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. References were exported and duplicates were removed using the title and abstract. The above became the aim of this study. https://doi.org/10.5694/j.1326-5377.2009.tb02487.x. An official website of the United States government. 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]. 2009;17(4):32732. Cite this article. DOI: Hearing SD. Studies identified 1) a wide range of refeeding regimes depending on country, settings, and the reason for initiation; 2) standard practice is to introduce Nasogastric feeds (NG) if medically unstable or oral intake alone is inadequate; 3) NG may enable greater initial weight gain due to increased caloric intake; 4) there are 3 main types of feeding regime: continuous, nocturnal and bolus; 5) complications included nasal irritation, epistaxis, electrolyte disturbance, distress and tube removal; 6) where NG is routinely implemented to increase total calorie intake, length of stay in hospital may be reduced; however where NG is implemented in correlation to severity of symptoms, it may be increased; 7) both medical and psychiatric wards most commonly report using NG in addition to oral intake. Unfortunately, owing to the high heterogeneity of data, summary incidence measures are meaningless. Fuller S, Street O, Hudson L, Nicholls D. Enteral feeding young people with anorexia nervosa under restraint in inpatient settings. RH was found in 37% (10/27). The decrease of nutritional status has affected one-third hospitalized patients, while there is no widely used definition of malnutrition. It is important to note that only a subset of patients with heightened risk will develop this life-threatening complication during nutritional rehabilitation. https://doi.org/10.1016/j.jadohealth.2009.11.207. For more information about refeeding syndrome symptoms and warning signs, contact us. These include: Refeeding syndrome can cause sudden and fatal complications. 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. After removing duplicates, 975 records were screened for titles and abstracts, and then, after excluding articles not meeting the inclusion criteria, 107 full papers were assessed for eligibility and 35 articles met the criteria for the inclusion in the analysis. https://doi.org/10.1177/0148607106030003231. The IF Center at the Stanley Dudrick's Memorial Hospital in Skawina is one of the biggest centers in Poland, celebrating its twentieth birthday last year. 2016;58(6):6419. Agostino and colleagues [23] delivered nutrition on a medical ward solely via NG for 14days before commencing oral diet in addition to NG feeding. Pragmatic, prospective studies that control for this confounder are required for any such comparison to be made. 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. J Nutr Metab. 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). An Australian study [45] (conducted in a paediatric unit) found YP viewed being NG fed as: an unpleasant experience, a necessary intervention, a psychological signifier of illness, and an emphasis in an underlying struggle for control. Copyright 2023 Elsevier B.V. or its licensors or contributors. Consequently, poor muscle status, determined by CT imaging, does not justify denying a patient an oncologic resection. A comprehensive database search of AMED, EMBASE, APA Psychinfo and MEDLINE was performed with no language restriction from January 2000 to July 2020. 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. In other words, the lower a patients weight, the higher their risk for this complication during refeeding. One of the main guidelines used for the evaluation and treatment of refeeding syndrome is the National Institute for Health Care and Excellence (NICE) Nevertheless, a bundle of variables could be identified to empirically assess the magnitude of both values. All authors assessed bias risk. DOI: Mehanna HM, et al. Complications of refeeding syndrome can be prevented by electrolyte infusions and a slower refeeding regimen. Healthcare professionals can prevent complications of refeeding syndrome by: Refeeding syndrome appears when food is introduced too quickly after a period of malnourishment. 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]. Butyric acid levels also correlated with several clinical/echocardiographic factors in DCM patients. < 40%. Certain conditions may increase your risk for this condition, including anorexia, alcohol use disorder, and more. https://doi.org/10.1002/ncp.10187. ACUTE Earns Prestigious Center of Excellence Designation from Anthem Increasing awareness and using screening programs to identify those at risk of developing refeeding syndrome are the next steps in improving the outlook. All rights reserved. Earley T. Improving safety with nasogastric tubes: a whole-system approach. In the absence of carbohydrates, the body turns to stored fats and proteins as sources of energy. 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. J Human Nutr Dietetics. Couturier and Mahmood [29] highlighted that meal support therapy reduced the requirement for NG feeding from 66.7 to 11.1%, criteria for NG feeding was the same in both groups throughout and oral intake was encouraged. Higher caloric refeeding is safe in hospitalised adolescent patients with restrictive eating disorders. There were no studies from Asia, South America or Africa. https://doi.org/10.1093/pch/pxx063. 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. To evaluate the influence of the SMI and MRA on post-surgery complications, logistic regression models were used. While there is no single definitive marker to identify which patients will develop refeeding syndrome, the National Institute for Health and Clinical Excellence (NICE) has published two sets of criteria for identifying patients at heightened risk for this complication. The risk of bias was deemed to be medium or high (see Additional file 1: Appendix 2) for the majority of the studies included due to the nature of their design, being case series or retrospective cohort studies. Intravenous (IV) infusions based on body weight are often used to replace electrolytes. Rhabdomyolysis can occur (causing an elevated creatinine kinase). However, it typically follows a period of: Certain conditions may increase your risk for this condition, including: Certain surgeries may also increase your risk. Refeeding is the process of reintroducing food after malnourishment or starvation. WebThe current NICE guidelines poorly predict the occurrence of RH, and modification is likely beneficial. Hyperglycemia can induce the heart to enter an oxygen-restricted environment, which results in diabetic cardiomyopathy (DCM). 2023 BioMed Central Ltd unless otherwise stated. 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. Application criteria of enteral nutrition in patients with anorexia nervosa: correlation between clinical and psychological data in a lifesaving treatment. Early RFH was significantly associated with a 56% longer PICU stay (p=0.003) and 42% longer hospital stay (p=0.007), but not with new infections (OR 2.01 (95% CI 0.90; 4.30), p=0.08) or length of mechanical ventilatory support (OR 1.05 (95% CI3.92; 6.03), p=0.68), when adjusted for possible confounders. Refeeding syndrome awareness, prevention, and management. AustralasPsychiatry. The American Society of Parenteral and Enteral Nutrition (ASPEN) has proposed the definition of refeeding syndrome shown below (32115791). Paediatr Child Health. sharing sensitive information, make sure youre on a federal government site. Anorexia nervosa. For nocturnal feeds, oral diet was encouraged during the day. 2019;8(3):1248. Inclusion in an NLM database does not imply endorsement of, or agreement with, Therefore, it is important for all patients with extreme forms of anorexia and ARFID to initiate nutritional rehabilitation in an inpatient medical setting that specializes in preventing, identifying and managing this potentially fatal complication. 2014;71(2):1007. The anabolic processes require minerals and coenzymes such as thiamine [4,6]. Three studies reported weight gain in the context of inadequate oral intake [9, 18, 39]. The results of this review support the conclusions from Rizzo and colleagues [49] (2019) that NG feeds can be safely administered and have the advantage of shortening LOS when used to increase total caloric intake. The use of enteral nutrition in the treatment of eating disorders: a systematic review. Refeeding syndrome commonly occurs in populations at high risk for malnutrition ranging from patients with eating disorders to renal failure patients on 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. Nutr Clin Pract. 2016;2016:19. Webreport, literature review and clinical guidelines. EDs usually manifest prior to adulthood, with an average age of onset of approximately 15years, although this is decreasing; with new research from NICE demonstrating that incidence in children aged 12 and under had increased between 2005 and 2015 in the UK [2, 3]. 69.) Anorexia nervosa, anxiety, and the clinical implications of rapid refeeding. By continuing you agree to the use of cookies. A total of 1247 patients were eligible (618 early-PN, 629 late-PN). 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. 1 study [39] included only Caucasian participants however the majority of studies were conducted in affluent, Caucasian majority countries; 31% of the studies included were set in Australia, 14% in the USA, 10% in Canada. Monitor electrolytes carefully. The pooled length of stay of 2965 patients with refeeding syndrome in 11 studies was 25.55 (95% CI, 20.2030.90) days. Agostino H, Erdstein J, Di Meglio G. Shifting paradigms: continuous nasogastric feeding with high caloric intakes in anorexia nervosa. Our study suggests more standardized methods of caloric intake are needed in resource-limited settings with high co-prevalence of PEM and TB. Paccagnella A, Mauri A, Baruffi C, Berto R, Zago R, Marcon ML, et al. Nurs Stand. 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). Learn the difference between these two conditions. This exploratory study is based on the data from the Supplemental Parenteral Nutrition study 2 (SPN2), which measured EGP and GNG at days 4 and 10 in 23 critically ill patients. 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. Prevention is critical in avoiding the life-threatening complications of refeeding syndrome. We therefore advocate septic screening and a low threshold for broad spectrum antibiotic cover for any patients with unexplained hypothermia, hypoglycaemia, and evidence of malnutrition. There are many vegan protein powders on the market, with a variety of flavors and ingredients available. 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 ]. WebThe NICE (National Institute for Health and Clinical Excellence) in England has listed criteria for identifying a patient who may be at increased risk for refeeding problems.