Phone: 866.485.6911, 2020 ACUTE Center for Eating Disorders & Severe Malnutrition by Denver Health. 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]. J Dev Behav Pediatr. However, due to the high heterogeneity of data, summary incidence measures are meaningless. The pooled length of stay of 2965 patients with refeeding syndrome in 11 studies was 25.55 (95% CI, 20.2030.90) days. 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. https://doi.org/10.1016/j.encep.2012.06.001. Controlled studies of patients refeeding process with the outcome of length of stay were included. KH and CF performed search of databases and created the document. AHRQ publication no. Univariate, unadjusted long-term survival analysis revealed that lower MRA and lower SMI were associated with shorter survival (P=0.03). 2 studies [21, 47] examined male only cohorts but both were high risk of bias. 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 The most common primary disease was cancer (n=267), followed by mesenteric ischemia (n=104), and surgical complications (n=62). Beyond the Banana Bag: Treating Nutritional (2015). 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. In this study the mean LOS was significantly increased: 117days for YP managing oral intake compared to 180days for those requiring NG. Google Scholar. Adolescents with severe restrictive eating disorders often require enteral feeding to provide lifesaving treatment. Wernicke encephalopathy (ocular abnormalities, ataxia, delirium), Weakness (including respiratory muscle weakness). A history of alcoholism or misuse of certain drugs, such as insulin, chemotherapy drugs, diuretics or antacids. The optimal cutoff is unclear, possibly an absolute serum phosphate level below ~1.5 mg/dL (0.5 mM). Web1 Identification of Refeeding Syndrome Risk 2 Nutritional Care Planning for patients deemed at risk of Refeeding Syndrome 3 Medical advice regarding electrolyte and Our results suggest that a robust model might be built, but requires a prospective study including a larger number of patients. Increase of parenteral nutrition intake (in % kcal of predicted resting energy expenditure) decreased phosphate concentrations (c=0.002 (95% CI -0.002;0.001). Whitelaw M, Gilbertson H, Lam PY, Sawyer SM. Int J Eat Disord. 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. of 18.5% and 29.9%. Neiderman M, Zarody M, Tattersall M, Lask B. Enteric feeding in severe adolescent anorexia nervosa: a report of four cases. 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. Hypophosphatemia is a common feature of refeeding syndrome. Consequently, the reported incidence rates varied between 0% and 80% depending on the definition and the population studied [2,8]. Food deprivation changes the way your body metabolizes nutrients. 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. Street K, Costelloe S, Wooton M, Upton S, Brough J. 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). Fuller S, Street O, Hudson L, Nicholls D. Enteral feeding young people with anorexia nervosa under restraint in inpatient settings. Akgul S, Pehlivanturk-Kizilkan M, Ors S, Derman O, Duzceker Y, Kanpur N. Type of setting for the inpatient adolescent with an eating disorder: are specialized inpatient clinics a must or will the pediatric ward do? It is not possible from this review to discern the advantages and disadvantages of each method as no study made a direct comparison. Regulation of endogenous glucose production (EGP) is essential for glucose homeostasis. 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. Whenever possible, attempt to provide the. Copyright 2023 Elsevier B.V. or its licensors or contributors. The average length of stay in patients with refeeding syndrome was 25.55 days with a very high heterogeneity between studies. To overcome this challenge, a new statistical approach is proposed in this study: analyzing the linear association of computer tomography derived muscle parameters with important clinical short- and long-term outcomes post esophagectomy, regardless of cut-offs. Neither of these guidelines are specific for children and adolescents. The inclusion criteria were: NG feeding, participants under 18years, eating disorders, published since 2000 and primary research. NICE guidelines regarding refeeding syndrome, based on a very cautious refeeding regime reaching estimated calorie and protein needs within 7 days, compared Other metabolic changes can also occur. This study aims to examine BG outcomes in the context of nutritional management during GC. In Australian based studies, NG was given due to refusal of oral intake in 2 studies [9, 10] as well as to treat medical instability [26]. 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 syndrome commonly occurs in populations at high risk for malnutrition ranging from patients with eating disorders to renal failure patients on 2006;30(3):2319. Roux H, Chapelon E, Godart N. Epidemiology of anorexia nervosa: a review. All rights reserved. Fabrizio Pasanisi: Visualization, Writing - Review & Editing. The majority of studies included were retrospective and based around case note reviews which are subjective and therefore likely to be biased. These studies discussed ceasing NG feeds after the risk of RS had reduced; most gave a time frame between 2 and 14days [24, 44]. 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. A number of YP in MH wards required restraint to NG feed with one study reporting this was required for 66% of YP [24]. People who are at risk of heart-related complications may require heart monitoring. Quality assessment, including risk of bias, was conducted by all authors. BMJ Open. It includes gluconeogenesis (GNG) from non-carbohydrate substrates and hepatic glycogenolysis. Before In the absence of carbohydrates, the body turns to stored fats and proteins as sources of energy. Falcoski P, Philpot U, Tan J, Hudson LD, Fuller SJ. Many sources recommend starting conservatively (e.g., 50% energy requirement), with gradual advancement. 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. Learn the difference between these two conditions. 2019;115(12):501. Background The incidence of refeeding syndrome (RFS) in critically ill patients is high, which is detrimental to their prognoses. specialist registrar gastroenterology and clinical nutrition. In the present review, we concluded that higher initial calorie intake may help shorten the length of stay in patients with malnutrition. Outcomes of an inpatient refeeding protocol in youth with anorexia nervosa: Rady Childrens hospital San Diego/University of California, san Diego. A secondary care hospital in rural India serving a highly tuberculosis (TB) and malnutrition endemic region. Refeeding Syndrome Unfortunately, owing to the high heterogeneity of data, summary incidence measures are meaningless. 2013;39(2):8593. 152-158, The incidence of the refeeding syndrome. This systematic review sets out to Patients with RH underwent further evaluation for RFS-associated findings. (2014). A total of 4679 records were identified in the initial literature search. Syndrome 2019;34(3):35970. 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%. PubMed, Embase, Cochrane Library, Web of Knowledge, and two Chinese databases were systematically searched until October 2021. 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. Psychol Med. guidelines (2011). Refeeding syndrome is a serious and potentially fatal condition that can occur during refeeding. https://doi.org/10.1176/appi.ajp.159.8.1347. Hay AP, Chinn D, Forbes D, Madden S, Newton R, et al. McCray S, et al. Two studies examined therapeutic interventions to reduce the need for NG or length of time on it in medically stable YP [29, 41]. Nutritional Assessment - BAPEN Refeeding is the process of reintroducing food after malnourishment or starvation. 2002;159(8):134753. 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. Youve taken in little to no food for the past 5 or more consecutive days. NG feeding may be administered through different methods such as continuously, multiple single meals (bolus), or overnight to supplement day-time oral intake. Nutritional glucose intake affects blood glucose (BG) outcomes, but few protocols actively control it. In 2006, the National Institute for Health and Clinical Excellence (NICE) published a risk-assessment tool for the definition of the RFS risk [9]. 69.) Four databases were systematically searched until September 2020 for retrieving trials and observational studies. DOI: Lambers WM, et al. Meal support therapy reduces the use of nasogastric feeding for adolescents hospitalized with anorexia nervosa. 3729-3740, Clinical Nutrition, Volume 40, Issue 6, 2021, pp. 2017;5(1):110. Muscle radiation attenuation (MRA) was measured to evaluate muscle quality. A total of 1247 patients were eligible (618 early-PN, 629 late-PN). Studies published in languages other than English were translated prior to being reviewed. Our experts continually monitor the health and wellness space, and we update our articles when new information becomes available. Shifts in electrolyte levels can cause serious complications, including seizures, heart failure, and comas. Extended period NPO (>5 days). For more information about refeeding syndrome symptoms and warning signs, contact us. Rizzo SM, Douglas JW, Lawrence JC. Webreport, literature review and clinical guidelines. Online Medical Education on Emergency Department (ED) Critical Care, Trauma, and Resuscitation. For example, in Australian studies medical wards tended to include high levels of psychiatric treatment alongside medical treatment [26]. The PRISMA flowchart was used (Fig. J Adolesc Health. 3677-3687, Clinical Nutrition, Volume 40, Issue 6, 2021, pp. The .gov means its official. London: National Institute for Health and Care Excellence (UK); 2017. 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. A brief historical perspective has been added to better illustrate the center's growth and transformation. Guidelines help identify patients at elevated risk for developing this life-threatening complication of reintroducing calories in the early stages of anorexia nervosa treatment. Anorexia nervosa, anxiety, and the clinical implications of rapid refeeding. As a result, people at risk require medical supervision at a hospital or specialized facility. The use of enteral nutrition in the treatment of eating disorders: a systematic review. 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. When carbohydrate consumption is significantly reduced, insulin secretion slows. This review aims to assess strategies for the use, tolerance and effectiveness of NG feeding in YP with restrictive ED. https://doi.org/10.24953/turkjped.2016.06.010. 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. Prevention is critical in avoiding the life-threatening complications of refeeding syndrome. 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. 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. 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). https://doi.org/10.1002/ncp.10187. Thirty-five observational studies were included in the analysis. (2001). 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. Start vitamin B12 (cyanocobalamin) 1,000 micrograms orally twice daily. Refeeding Syndrome: Problems with Definition and Management. A review conducted by Rizzo and colleagues [49] (2019), which focused on NG for acute refeeding, also found a wide variety of practices. Strik Lievers and colleagues [44] concluded that, amongst others, requirement for NG feeding when NG was implemented due to medical instability was a factor affecting LOS on a psychiatric ward. (2009). A broader view of electrolyte shifts may be a welcome addition, given that prior definitions have focused excessively on phosphate. The association between baseline characteristics and early RFH, and the association of early RFH with clinical outcome were investigated using logistic and linear regression models, both uncorrected and corrected for possible confounders. Overall, 39% (57/146) of all responders thought the guidance represented safe practice, whereas 36% (53/146) thought they were excessively cautious. Refeeding Syndrome Among Older Adults The correlation between EGP and GNG and 83 potential clinical indicators were explored, using single-stage and multivariate analysis. 2012;27:3440. Guidance 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. A subset of patients receiving high glucose nutrition under IO were persistently hyperglycaemic, indicating patient-specific glucose tolerance. 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. Refeeding syndrome: A literature review. Privacy Halse C, Broughtwood D, Clarke S, Honey A, Kohn M, Madden S. Illumating multiple perspectives: meaning of nasogastric feeding in anorexia nervosa. Restore circulatory volume and monitor fluid balance and overall clinical status closely. ;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 During the acute refeeding phase the need for weight restoration must be balanced against the risk of developing RS. Clausen L, Larsen JT, Bulik CM, Peterson L. A Danish register-based study on involuntary treatment in anorexia nervosa. This definition is somewhat unique in its incorporation of potassium and magnesium changes. This leads to another condition called hypophosphatemia (low phosphate). Changes in these symptoms were not attributed to the rate of weight restoration suggesting a rapid refeeding schedule would not exacerbate psychiatric symptoms. Most studies tailored the calorie requirements to the individual patient, accounting for initial weight for height percentage and signs of medical instability. Refeeding syndrome symptoms and warning signs typically appear early in the refeeding process, and require immediate medical intervention upon observation. Hyperglycemia can induce the heart to enter an oxygen-restricted environment, which results in diabetic cardiomyopathy (DCM). Earley T. Improving safety with nasogastric tubes: a whole-system approach. Structured, supported feeding admissions for restrictive eating disorders on paediatric wards. PubMed 2005;13(4):26472. Refeeding Certain conditions, such as anorexia nervosa or chronic alcohol use disorder, can increase risk. (2004). Results demonstrated that YP receiving PLT had a significantly reduced requirement for NG (P<0.05). Refeeding syndrome: What it is, and how to prevent and treat it. The reintroduction of enteral or parenteral nutrition, leading to refeeding hypophosphatemia (RFH), has been presented as potential risk factor. Treatment of patients with eating disorders. Nurs Times. Source: Garber AK, Cheng J, Accurso EC, et al. Madden S, Mskovic-Whaetley J, Clarke S, Touyz S, Hay P, Kohn MR. Outcomes of a rapid refeeding protocol in adolescent anorexia nervosa. People who are malnourished are at risk. Kwashiorkor and Marasmus: Whats the Difference? https://doi.org/10.1002/eat.22968. J Eat Disord. All authors have reviewed the document and consent to publication. J Eat Disord 9, 90 (2021). British Dietetic Association. 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/10.1002/erv.624. Patients with renal replacement therapy or unavailable phosphate concentrations were excluded from this analysis. A systematic review of approaches to refeeding in patients with anorexia nervosa. Eur J Clin Nutr. There is a low risk of complications associated with NG feeding if staff receive adequate training and protocols are enforced to ensure that the tube has been passed correctly [11]. 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. Follow lytes including Mg & Phosphate for three 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. 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. Child and adolescent mental health service, Preferred Reporting Items for Systematic Reviews and Meta-Analyses, National Guideline Alliance (UK). Our multivariate model could predict EGP at day 4 (VCO2, glucose and energy intake) with an error coefficient (e.c.) NG under restraint was described as causing distress and risk of injury to both staff and YP [48]. In addition, the incidence of RH was also assessed since it is considered the hallmark of the syndrome. 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. J Nutr Metab. High Protein Feeds in Refeeding Syndrome Paccagnella A, Mauri A, Baruffi C, Berto R, Zago R, Marcon ML, et al. After electrolyte levels stabilize, increase caloric intake to 40 kCal/hr for a day, then increase to 60 kCal/hr for a day. 2014;48(11):9771008. The new guidelines give explicit clinical criteria for patients at risk and highly at risk of developing refeeding syndrome, enabling better identification and prevention Until recently, refeeding syndrome (RFS) has lacked standardized diagnostic criteria. < 40%. 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]. For example, insulin is a hormone that breaks down glucose (sugar) from carbohydrates. 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]. Complications associated with NG feeding found in this review are summarised in Table 2, with the most frequently described being nasal irritation or epistaxis, anxiety related to the procedure and electrolyte disturbance (which occurred with both oral and NG refeeding). Nutr Clin Pract. 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]]. Maginot et al. Attitudes to NICE guidance on refeeding syndrome - ResearchGate Yet again, the incidence is Evidence report/technology assessment no. 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, J Adolesc Health.
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