Figure1 displaying PRISMA flowchart of methodology utilised to search databases for this systematic review of enteral feeding in young people with restrictive eating disorders. 2018;33(6):7905. J Adolesc Health. 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. Parker E, Faruquie S, Anderson G, et al. This systematic review sets out to describe current practice of NG in young people with eating disorders. Many sources recommend starting conservatively (e.g., 50% energy requirement), with gradual advancement. The potential risk of refeeding syndrome should be considered whenever starting any previously underfed patient on nutrition. (2004). 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]. Treatment usually involves replacing essential electrolytes and slowing down the refeeding process. Fabio Bioletto: Data curation, Writing - Review & Editing. However, if the analysis was adjusted for confounders, e.g., Charlson Comorbidity Index, no relevant association regarding long-term survival was detected. Accessibility This could have the advantage of reducing LOS in medically stable YP. Patients with renal replacement therapy or unavailable phosphate concentrations were excluded from this analysis. There were no studies from Asia, South America or Africa. For patients with the highest risk of refeeding syndrome, starting with 5 kcal/kg/day might even be considered (e.g., for a patient with BMI <14 kg/m2 and no nutritional intake for two weeks). https://doi.org/10.1177/0148607106030003231. Muscle radiation attenuation (MRA) was measured to evaluate muscle quality. WebThese guidelines have been written to provide guidance for medical, dietetic and nursing staff managing patients with severe malnutrition and/or at risk of refeeding syndrome Wernicke encephalopathy (ocular abnormalities, ataxia, delirium), Weakness (including respiratory muscle weakness). Low baseline levels of K/Phos/Mg. Unfortunately, owing to the high heterogeneity of data, summary incidence measures are meaningless. A major cause of refeeding syndrome seems to be an endogenous insulin surge, which is triggered by carbohydrate intake. Federal government websites often end in .gov or .mil. Catabolic state (e.g., due to infection or surgery). The reintroduction of enteral or parenteral nutrition, leading to refeeding hypophosphatemia (RFH), has been presented as potential risk factor. If you're underweight and looking to gain weight, it's very important to do it right. Our website services, content, and products are for informational purposes only. Naso-gastric or nasogastric or *enteric or *enteral or tube, (Anorexia or bulimia or eat* or feed*) NOT bowel NOT surgery NOT intestin*, (child* or paed* or adolescen* or teen* or young) NOT baby NOT toddler NOT infant NOT animal NOT maternal NOT parental NOT learning disabl* NOT learning disabil*. https://doi.org/10.5694/j.1326-5377.2009.tb02487.x. Conclusions: The strategy for assessing the risk of refeeding syndrome, nutritional management and implemented follow-up were successful in preventing the Though some people who are at risk dont develop symptoms, theres no way to know who will develop symptoms before beginning treatment. Moreover, for clinicians, there is currently conflicting guidance on how to manage NG feeding in YP with ED, in particular how and when to transition between oral and NG feeding [20, 21]. NG was also implemented due to acute refusal of food or inability to meet oral intake, without significant medical instability, in five studies [9, 10, 18, 31, 43]. Healthcare professionals can prevent complications of refeeding syndrome by: Refeeding syndrome appears when food is introduced too quickly after a period of malnourishment. Available from: https://www.ncbi.nlm.nih.gov/books/NBK436876/. 2011;19:52630. NICE guidelines regarding refeeding syndrome, based on a very cautious refeeding regime reaching estimated calorie and protein needs within 7 days, compared There are currently over 700,000 individuals in the UK with an eating disorder (ED) [1]. Increasing awareness and using screening programs to identify those at risk of developing refeeding syndrome are the next steps in improving the outlook. PubMed, Embase, Cochrane Library, Web of Knowledge, and two Chinese databases were systematically searched until October 2021. 3729-3740, Clinical Nutrition, Volume 40, Issue 6, 2021, pp. https://doi.org/10.24953/turkjped.2016.06.010. 2019;9(10):e027339. See, treatment of established refeeding syndrome, Treatment of established refeeding syndrome, https://traffic.libsyn.com/secure/ibccpodcast/IBCC_EP_83_-_Refeeding_Syndrome.mp3. NICE clinical guideline 32 (2006) criteria for recognising patients Refeeding syndrome is caused by sudden shifts in the electrolytes that help your body metabolize food. and transmitted securely. https://doi.org/10.1002/eat.20164. guidelines Kwashiorkor and Marasmus: Whats the Difference? A review conducted by Rizzo and colleagues [49] (2019), which focused on NG for acute refeeding, also found a wide variety of practices. Maginot et al. J Eat Disord 9, 90 (2021). Twenty-nine studies met the full criteria. The authors found a similarly large variability of the incidence for RFS (062%) as Friedli et al. 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]. A randomized controlled trial of in-patient treatment for anorexia nervosa in medically unstable adolescents. Purpose: To identify a patient who may be at risk for the refeeding syndrome based on the NICE criteria. The 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. Robb AS, Silber TJ, Orwell-Valente JK, et al. In the subgroup analyses, inpatients from Intensive Care Units (ICUs) and those initially fed with >20kcal/kg/day seemed to have a higher incidence of both RFS (pooled incidence=44%; 95% CI 36%52%) and RH (pooled incidence=27%; 95% CI 21%34%). Naso-Gastric Tube Feeding under restraint best practice guidelines for Dietitians 2019. Globally studies from North America [18, 21, 39, 41] and Turkey [36] focused on medical instability in YP with ED. WebRefeeding syndrome is defined as the potentially fatal shifts in fluids and electrolytes that may. Refeeding syndrome is a potentially fatal complication which generally occurs within 24-72 hours after starting nutrition (although it may occur later on). The incidence of refeeding syndrome is difficult to determine, as there isnt a standard definition. A broader view of electrolyte shifts may be a welcome addition, given that prior definitions have focused excessively on phosphate. 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. If youre recovering from an eating disorder or wanting a more positive relationship to food, these apps can. Int J Mental Health Nursing. Guidance 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. Significant discrepancy (>700 calories) was noted between nurse-estimated caloric intake compared to digital images. Eur Eat Disord Rev. https://doi.org/10.1176/appi.ajp.159.8.1347. Refeeding Protocol in Anorexia Nervosa Re-examined Manage cookies/Do not sell my data we use in the preference centre. Overall, 39% (57/146) of all responders thought the guidance represented safe practice, whereas 36% (53/146) thought they were excessively cautious. The catheter infection rate reached 0.39/1000 catheter days. Home parenteral nutrition (HPN) is one of the most demanding medical therapies as it is the only option for patients for intestinal failure (IF). Start vitamin B12 (cyanocobalamin) 1,000 micrograms orally twice daily. Refeeding syndrome symptoms and warning signs typically appear early in the refeeding process, and require immediate medical intervention upon observation. Electrolyte levels are monitored with frequent blood tests. WebRefeeding Syndrome in Patients Receiving Parenteral Nutrition Is Not Associated to Mortality or Length of Hospital Stay: A Retrospective Observational Study Bias can also occur due to the different treatment groups being recorded at different times thus confounding variables may include different staff working at the setting and therefore different methods of treating YP. JM was responsible for references and editing. None developed clinical RFS. All rights reserved. Copyright 2023 Elsevier B.V. or its licensors or contributors. 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. https://doi.org/10.12968/bjmh.2019.8.3.124. London: National Institute for a Clinical Excellence; 2004. Madden et al [22] RCT determined the duration of NG feeding was a minimum of 14days, using biochemical markers of medical instability in a hospital setting. Interestingly, butyric acid levels positively correlated with HIF3A levels, while a negative association was identified between butyric acid levels and the methylation rates of HIF3A intron 1at CpG 6. 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). CR168s Summary of Junior Marsipan: Management of really sick patients under 18 with Anorexia Nervosa. However, this study does not discuss the reasons NG was implemented. ACUTE Earns Prestigious Center of Excellence Designation from Anthem NICE. To keep this page small and fast, questions & discussion about this post can be found on another page here. For nocturnal feeds, oral diet was encouraged during the day. Consequently, poor muscle status, determined by CT imaging, does not justify denying a patient an oncologic resection. Retrospective cohort analysis of 5 glycaemic control cohorts spanning 4 years (n=273) from Christchurch Hospital Intensive Care Unit (ICU). This appeared to be either after each meal, at set times during the day or once in the evening [27]. 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). 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. The flowchart relative to the selection process is reported in Fig. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Bayes A, Madden S. Early onset eating disorders in male adolescents: a series of 10 inpatients. Effect sizes were expressed as 95% confidence intervals (CIs) and calculated using random-effects models. Refeeding syndrome is a serious and potentially fatal condition that can occur during refeeding. The author(s) read and approved the final manuscript. https://doi.org/10.1002/erv.624. Furthermore, no relevant association to lengths of stay in intensive care or hospital were detected. Anorexia nervosa. Youve lost more than 15 percent of your body weight in the past 3 to 6 months. A total of 4679 records were identified in the initial literature search. Overall, these manifestations are variable and insensitive tools for detecting refeeding syndrome. Prevention is critical in avoiding the life-threatening complications of refeeding syndrome. Madden S, Mskovic-Whaetley J, Clarke S, Touyz S, Hay P, Kohn MR. Outcomes of a rapid refeeding protocol in adolescent anorexia nervosa. https://doi.org/10.1080/10640260902991236. Thirty-five observational studies were included in the analysis. People who are malnourished are at risk. 2005;38(2):1436. The studies were analysed for risk of bias independently by CF, KH and JM. EMCrit is a trademark of Metasin LLC. By continuing you agree to the use of cookies. Roux H, Chapelon E, Godart N. Epidemiology of anorexia nervosa: a review. Increase of parenteral nutrition intake (in % kcal of predicted resting energy expenditure) decreased phosphate concentrations (c=0.002 (95% CI -0.002;0.001). The subjects at risk of developing RFS are characterized by reduced insulin secretion and increased glucagon release, with a metabolic shift towards the utilization as energy sources of proteins and fats instead of glucose with resulting muscle mass loss, and a decrease in intracellular vitamins and minerals, particularly phosphate, potassium, and magnesium, due to undernutrition [4]. 27 patients were enrolled. NG feeding is a safe and efficacious method of increasing total calorie intake by either supplementing oral intake or continuously. Nutr Clin Pract. Youve taken in little to no food for the past 5 or more consecutive days. It comes after a rigorous review process. 2016;58(6):6419. Anorexia nervosa, anxiety, and the clinical implications of rapid refeeding. Side effects are minimal but may include nasal bleeding or irritation, and imbalances in blood electrolytes which can be reduced by providing supplementation. Refeeding syndrome is an important complication of refeeding in previously malnourished patients [11]. In the circumstances that their BMI is detrimentally low, a nasogastric (NG) tube may be placed from nose to stomach to pass nutrition. Refeeding syndrome is a severe complication of refeeding in people with malnutrition, it includes a series of electrolyte disorders and clinical symptoms. 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]. They are at even greater risk of precipitate falls in these circulating electrolytes once simultaneous nutritional and fluid therapy has started. This site represents our opinions only. Therefore, a universally accepted definition for the RFS is needed for evaluating its incidence and management in different. Development and validation of risk prediction model for Meal support therapy reduces the use of nasogastric feeding for adolescents hospitalized with anorexia nervosa. Intravenous (IV) infusions based on body weight are often used to replace electrolytes. 2019;34(3):35970. Robb et al [39] compared nocturnal NG feeding to supplement oral diet (maximum 3255 kcals /d) with oral intake (max 2508 kcals/d) reporting nocturnal NG feeding weight gain of 5.4kgs versus 2.4kgs in the oral diet only group. Learn more about this condition, what it means for those with diabetes, and why it's so important to find treatment and help. No study reported a YP developed RS. https://doi.org/10.1002/erv.2614. KH and CF performed search of databases and created the document. 2009;190(8):4104. Extended period NPO (>5 days). This has resulted in a variety of NG feeding practices across different settings, with many medical wards tending to provide continuous NG feeds and cease oral intake in order to medically stabilise the patient [20, 22,23,24,25,26]; in contrast mental health wards or specialized eating disorder programs housed on medical wards may be more likely to use syringe bolus feeds to provide food when meals are refused, encouraging oral intake and aiding normalisation of eating [9, 18, 27,28,29,30,31]. Other metabolic changes can also occur. Available literature suggests the following interventions may be reasonable: Want to Download the Episode?Right Click Here and Choose Save-As. Refeeding Syndrome Guideline 2023 Healthline Media LLC. PLT was based on FBT and included parents reducing child exercise and increasing oral intake. Esophageal cancer patients often suffer from cancer-related malnutrition and, as a result, sarcopenia. It's unclear whether IV thiamine is absolutely required here, or whether oral thiamine would be adequate. Refeeding Syndrome: Definition, Treatment, Risks, and More 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. Iolanda Cioffi: Conceptualization, Data curation, Methodology, Writing- Original draft preparation, Writing - Review & Editing. 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%. ssslideshare.com Some studies have demonstrated that the bioavailability of oral thiamine is substantial. 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. A blood test has revealed your serum phosphate, potassium, or magnesium levels are low. There is no high-quality evidence on this. 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. CF performed the discussion. DOI: Khan LUR, et al. https://doi.org/10.1186/s40337-016-0132-0. (1) Cessation of nutrition followed by refeeding. This consensus definition is additionally intended to be used as a basis for further research into the incidence, consequences, pathophysiology, avoidan During the acute refeeding phase the need for weight restoration must be balanced against the risk of developing RS. Denver, CO 80204 Nutritional glucose intake affects blood glucose (BG) outcomes, but few protocols actively control it. WebIv or oral multivitamins once daily for 10 days or greater based on clinical status Emad Zarief 2021 29 ASPEN Consensus recommendations for refeeding syndrome. Web1 Identification of Refeeding Syndrome Risk 2 Nutritional Care Planning for patients deemed at risk of Refeeding Syndrome 3 Medical advice regarding electrolyte and However, this new definition may be insufficiently specific for clinically relevent electrolyte changes and requires clinical validation. Scenario: Suspected eating disorder | Management 2006;163(7):454. Changes in these symptoms were not attributed to the rate of weight restoration suggesting a rapid refeeding schedule would not exacerbate psychiatric symptoms. J Human Nutr Dietetics. A number of YP in MH wards required restraint to NG feed with one study reporting this was required for 66% of YP [24]. Both these pathways are dysregulated in acute stress, but the magnitude of this deregulation cannot be assessed in clinical practice. 2015;3(1):8. https://doi.org/10.1186/s40337-015-0047-1. Background Adolescents with severe restrictive eating disorders often require enteral feeding to provide lifesaving treatment. https://doi.org/10.1002/eat.1040. We noted that despite RH being common in inpatients with PEM+TB given high caloric diets, RFS was not detected. 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. Although there is a significant body of research into this, the role of NG feeding remains ill-defined [17]. However, treatment providers should regularly monitor at-risk patients for symptoms of refeeding syndrome. Cookies policy. Hindley, K., Fenton, C. & McIntosh, J. Clausen L, Larsen JT, Bulik CM, Peterson L. A Danish register-based study on involuntary treatment in anorexia nervosa. volume9, Articlenumber:90 (2021) the contents by NLM or the National Institutes of Health. These include: Refeeding syndrome can cause sudden and fatal complications. Journal of Eating Disorders Refeeding Syndrome - PubMed Hay AP, Chinn D, Forbes D, Madden S, Newton R, et al. Research on NG feeding in YP has tended to focus on the acute refeeding phase in paediatric or psychiatric wards to reduce the risk of RS [17]. Check electrolytes (including magnesium and phosphate), with aggressive repletion as needed. Refeeding syndrome: A literature review. 2020;34:3341. Over time, this change can deplete electrolyte stores. 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. Leeds and York Partnership NHS Foundation Trust, Mill Lodge, 520 Huntington Rd, York, YO32 9QA, UK, You can also search for this author in Only 44% (8/19) of doctors compared with 70% (49/70) of dietitians followed the guidance. Refeeding Syndrome Among Older Adults It is not possible from this review to discern the advantages and disadvantages of each method as no study made a direct comparison. RS is historically described as a range of metabolic and electrolyte alterations occurring as a result of the rein- troduction 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. 2018;9:P1097. sharing sensitive information, make sure youre on a federal 2017;31(45):427. PubMed Its caused by sudden shifts in the electrolytes that help your DOI: Lambers WM, et al. Nasogastric (NG) feeding use in YP with ED may be used as a lifesaving treatment when patients are physically unwell [7, 8]. 69.) 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. A retrospective analysis of all medical records of HPN patients from the University Hospital and Stanley Dudrick's Memorial Hospital in Skawina. Article 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. Patients GC is delivered using a single model-based protocol (STAR), with default 4.48.0mmol/L target range via. There was a wide variety in length of time receiving NG for medical instability. 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]. Most EDs will be treated in an outpatient setting with hospitalisation generally reserved for those with severe malnutrition resulting in physical symptoms such as bradycardia, hypotension or dehydration as set out in the MARSIPAN guidance [16]. 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]. There are no other acknowledgements to be made. WebRefeedingSyndromeDefinitionandBackground. For this reason, acute medical intervention is often warranted in order to reduce mortality. National Collaborating Centre for Mental Health. 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. Higher caloric refeeding is safe in hospitalised adolescent patients with restrictive eating disorders. The inclusion criteria were: NG feeding, participants under 18years, eating disorders, published since 2000 and primary research. From beginners to advanced, Healthline has strict sourcing guidelines and relies on peer-reviewed studies, academic research institutions, and medical associations. Refeeding syndrome: What it is, and how to prevent and treat it. Refeeding syndrome is a serious and potentially fatal condition that can occur during refeeding. 2019;34(3):35970. Refeeding syndrome: (2021) Rapid renutrition improves health status in severely malnourished inpatients with AN - score-based evaluation of a high caloric refeeding protocol in The refeeding syndrome. Neiderman et al [40] qualitative study describes patients time receiving NG varying from 1 to 476days (methods not explained). American Psychiatric Association. Butyric acid levels also correlated with several clinical/echocardiographic factors in DCM patients. 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. systematic review of enteral feeding by nasogastric Eur J Clin Nutr. 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. Complications that require immediate intervention can appear suddenly. Less time spent being underfed may still result in refeeding syndrome if the patient were under, Abuse, neglect, inadequate access to food, Hyperemesis gravidarum or protracted vomiting, Malabsorption (e.g., inflammatory bowel disease, short gut syndrome, s/p bariatric surgery). Application criteria of enteral nutrition in patients with anorexia nervosa: correlation between clinical and psychological data in a lifesaving treatment. The anabolic processes require minerals and coenzymes such as thiamine [4,6]. There are clear risk factors for refeeding syndrome. Anorexia Nervosa in the Acute Hospitalization Setting Giovannino Ciccone: Visualization, Writing - Review & Editing, Supervision. All rights reserved. JPEN J Parenter Enteral Nutr. Depending on the severity of psychiatric and medical symptoms, patients may be admitted to a mental health or medical ward. In this study the mean LOS was significantly increased: 117days for YP managing oral intake compared to 180days for those requiring NG. Outcomes of an inpatient refeeding protocol in youth with anorexia nervosa: Rady Childrens hospital San Diego/University of California, san Diego. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. People who are at risk of heart-related complications may require heart monitoring. The use of enteral nutrition in the treatment of eating disorders: a systematic review. A systematic review of the published literature was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [15]. By comparison, IO only resulted in 6469% BG in range across different nutrition types. Fiber intake depends on age, gender, and sex. Whenever possible, attempt to provide the. Refeeding Syndrome 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]. 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. All selected studies had an observational design, 23 were retrospective cohort studies [. https://doi.org/10.1097/00004703-200412000-00005. 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. Some described NG feeds as easier than eating as it disguised the amount due to not swallowing; others felt it was a form of punishment for not gaining enough weight.
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