https://doi.org/10.1002/eat.20164. Titles and abstracts were screened by all authors before reviewing full length articles. 2019;24(2):17998. 2002;159(8):134753. Eat Disord. 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). Refeeding Syndrome: Prevention and Management Sydney Childrens Hospital Practice, Guideline June 2013 Crook MA. None developed clinical RFS. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. Int J Eat Disord. 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. Reduce the caloric intake to 20 kCal/hr for at least two days. Paccagnella A, Mauri A, Baruffi C, Berto R, Zago R, Marcon ML, et al. There were no studies from Asia, South America or Africa. A history of alcoholism or misuse of certain drugs, such as insulin, chemotherapy drugs, diuretics or antacids. 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. Eighteen studies involving 3868 participants were included in our review. Background The incidence of refeeding syndrome (RFS) in critically ill patients is high, which is detrimental to their prognoses. Eur Eat Disord Rev. (3) Absence of another obvious cause of hypophosphatemia that is felt to account for the hypophosphatemia. Does aggressive refeeding in hospitalized adolescents with anorexia nervosa result in increased hypophosphatemia? To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. 11 Historically, recommendations for nutritional rehabilitation in inpatient settings have been conservative, 12 16 for fear of precipitating the refeeding syndrome, a constellation of electrolyte disturbances and multiorgan dysfunction that can develop early in the 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. Although complications such as electrolyte abnormalities did occur there was no evidence that this was attributable to the NG feeding compared to oral diet [9, 18, 23, 24]. Univariate, unadjusted long-term survival analysis revealed that lower MRA and lower SMI were associated with shorter survival (P=0.03). 2018;51(11):121322. A systematic review of approaches to refeeding in patients with anorexia nervosa. 2019. https://www.nice.org.uk/guidance/qs24. If phosphate falls <1.5 mg/dL (0.5 mM) this indicates refeeding syndrome > see treatment below. old, P<0.05 [37] and 20% in early onset AN compared to 0% in adult onset AN P<0.05 [43]). Falcoski P, Philpot U, Tan J, Hudson LD, Fuller SJ. 2005;13(4):26472. PubMed The reintroduction of enteral or parenteral nutrition, leading to refeeding hypophosphatemia (RFH), has been presented as potential risk factor. However, this study does not discuss the reasons NG was implemented. Neiderman et al [40] qualitative study describes patients time receiving NG varying from 1 to 476days (methods not explained). https://doi.org/10.1038/ejcn.2013.244. Patients Permissive hyperglycemia could be safer than the administration of high doses of insulin. RS is historically described as a range of metabolic and electrolyte alterations occurring as a result of the rein- troduction 2016;101(9):8368. 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%. These studies discussed ceasing NG feeds after the risk of RS had reduced; most gave a time frame between 2 and 14days [24, 44]. If youre recovering from an eating disorder or wanting a more positive relationship to food, these apps can. Turk J Pediatr. Ann Intern Med. 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. Rocks T, Pelly F, Wilkinson P. Nutritional management of anorexia nervosa in children and adolescent inpatients: the current practice of Australian dietitians. 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. Though some people who are at risk dont develop symptoms, theres no way to know who will develop symptoms before beginning treatment. The majority also had a relatively small sample size, again introducing the possibility of bias and reducing generalizability. Side effects are minimal but may include nasal bleeding or irritation, and imbalances in blood electrolytes which can be reduced by providing supplementation. 1. 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. Significant discrepancy (>700 calories) was noted between nurse-estimated caloric intake compared to digital images. (2016). https://doi.org/10.1002/1098-108X(200012)28:4<470::AID-EAT18>3.0.CO;2-1. Refeeding syndrome: What it is, and how to prevent and treat it. Glucose intolerance and insulin resistance manifest as hyperglycaemia in intensive care, which is associated with mortality and morbidities. 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. Clausen L, Larsen JT, Bulik CM, Peterson L. A Danish register-based study on involuntary treatment in anorexia nervosa. Couturier J, Mahmood A. 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%). There are clear risk factors for refeeding syndrome. 2017;22(5):26972. 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]. Application criteria of enteral nutrition in patients with anorexia nervosa: correlation between clinical and psychological data in a lifesaving treatment. (NICE Guideline, No. Other metabolic changes can also occur. What Is Imitation Crab and Should You Eat It? Patients with RH underwent further evaluation for RFS-associated findings. It should be recognized that refeeding syndrome can occur among stressed ICU patients if nutrition is interrupted for only a short period of time (e.g., one week). Microbiota-derived short-chain fatty acids (SCFAs) affect O2 consumption and play crucial roles in modulating metabolic and cardiovascular health. The aim of this systematic review and meta-analyses was 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 American Society of Parenteral and Enteral Nutrition (ASPEN) consensus. https://doi.org/10.1002/erv.2614. As such, this might be most accurately termed carbohydrate refeeding syndrome.. Int J Mental Health Nursing. Accessibility Both these pathways are dysregulated in acute stress, but the magnitude of this deregulation cannot be assessed in clinical practice. PubMedGoogle Scholar. However, this will be the first systematic review on the use of NG feeding specifically in YP with ED. The use of enteral nutrition in the treatment of eating disorders: a systematic review. Petkova BH, Simic M, Nicholls D, Ford T, Prina AM, Stuart R. Incidence of anorexia nervosa in young people in the UK and Ireland: a national surveillance study. Shifts in electrolyte levels can cause serious complications, including seizures, heart failure, and comas. The modulation of insulin and nutrition. Nutritional glucose intake affects blood glucose (BG) outcomes, but few protocols actively control it. The pooled impact of refeeding syndrome on length of stay of 2634 patients in 10 studies was weighted mean difference (WMD)=2.91 (95% CI,0.18 6.00; P=0.065) days. For this reason, acute medical intervention is often warranted in order to reduce mortality. The refeeding syndrome. Pragmatic, prospective studies that control for this confounder are required for any such comparison to be made. 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. and transmitted securely. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. NG feeding involves a fine bore tube passed via the nasal passage into the stomach in order to administer nutrition. 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*. 2018;9:P1097. 2001;29(4):4418. Higher caloric refeeding is safe in hospitalised adolescent patients with restrictive eating disorders. https://doi.org/10.1002/eat.22968. To examine the impact of nutritional intake on phosphate concentrations, structural nested mean models with propensity score and censoring models were used. 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. The lack of a universally accepted definition, the non-specificity of the clinical manifestations of the RFS, the physician unawareness of the existence of the syndrome, make this potentially serious condition still frequently overlooked [13,14]. Our multivariate model could predict EGP at day 4 (VCO2, glucose and energy intake) with an error coefficient (e.c.) 2006;30(3):2319. A survey of dietitians found 82% considered NG feeding a necessary procedure if oral diet is inadequate [10]. There is a need for more high quality data in when to initiate NG, comparing different methods of delivering NG feeds and transitioning from NG to oral diet in YP with restrictive ED to enable future direction for clinicians. 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). Child and adolescent mental health service, Preferred Reporting Items for Systematic Reviews and Meta-Analyses, National Guideline Alliance (UK). DOI: hopkinsmedicine.org/gim/_pdf/consult/refeeding_syndrome.pdf, med.virginia.edu/ginutrition/wp-content/uploads/sites/199/2014/06/Parrish-September-16.pdf. JAMA Pediatr; doi: 10.1001/jamapediatrics.2020.3359Investigators from multiple PubMed Central We noted that despite RH being common in inpatients with PEM+TB given high caloric diets, RFS was not detected. This systematic review sets out to The risk of bias was serious in 16 studies and moderate in the remaining 19. 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]. Eur Eating Disord Rev. Clausen [46] described NG as the most frequently used involuntary measure in psychiatric practice and is most commonly used in 1517year olds. Terms and Conditions, Nehring and colleagues [37] concluded that NG feeding had no impact on growth, recovery or development of psychiatric co-morbidities. Fabrizio Pasanisi: Visualization, Writing - Review & Editing. https://doi.org/10.1186/s40337-016-0132-0. 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]. Treatment of patients with eating disorders. Maginot et al. 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. Learn what the terms cured and uncured bacon actually mean when you see them in the store. Enteral nutrition via nasogastric tube for refeeding patients with anorexia nervosa: a systematic review. 2011;19:52630. 2015;45(2):41527. 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. The site is secure. The 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]. Start vitamin B12 (cyanocobalamin) 1,000 micrograms orally twice daily. The decrease of nutritional status has affected one-third hospitalized patients, while there is no widely used definition of malnutrition. Iolanda Cioffi: Conceptualization, Data curation, Methodology, Writing- Original draft preparation, Writing - Review & Editing. 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. 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). clos Nutritional care pathway (NICE, 2006, BAPEN, 2007) Screen for malnutrition (using MUST screening tool) refeeding syndrome: 25-35 kcal/kg/day total energy INCLUDING that derived from protein 0.8 McCray S, et al. One study reported on weight gain where NG is routinely started on all ED YP regardless of context [23]. Thiamine (e.g., 500 mg IV q8hr, if mental status changes). Silber TJ, Robb AS, Orrell-Valente JK, Ellis N, Valadez-Meltzer A, Dadson MJ. By continuing you agree to the use of cookies. NICE. Agostino and colleagues [23] delivered nutrition on a medical ward solely via NG for 14days before commencing oral diet in addition to NG feeding. Rizo S, Douglas JW, Lawrence JC. 1. 2009;190(8):4104. Compared to other mental illnesses, EDs have a high mortality rate with young people (YP) with anorexia nervosa (AN) on average 610 times more likely to die than the general population [4, 5]. Psychol Med. 777 Bannock Street Garber AK, Sawyer SM, Golden NH, Guarda AS, Katzman DK, Kohn MR, et al. In some cases, refeeding syndrome can be fatal. 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. Its development is completely predictable. 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. https://doi.org/10.1016/j.jadohealth.2009.11.207. This review aims to assess strategies for the use, tolerance and effectiveness of NG feeding in YP with restrictive ED. Hale D, Logomarsino JV. There was a wide variety in length of time receiving NG for medical instability. For nocturnal feeds, oral diet was encouraged during the day. 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. Google Scholar. Restore circulatory volume and monitor fluid balance and overall clinical status closely. AustralasPsychiatry. 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. the contents by NLM or the National Institutes of Health. Eating Disorders: Recognition and Treatment. Refeeding syndrome. This consensus definition is additionally intended to be used as a basis for further research into the incidence, consequences, pathophysiology, avoidan 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. In the circumstances that their BMI is detrimentally low, a nasogastric (NG) tube may be placed from nose to stomach to pass nutrition. This systematic review sets out to describe current practice of NG in young people with eating disorders. https://doi.org/10.1176/appi.ajp.159.8.1347. DOI: Khan LUR, et al. The most common primary disease was cancer (n=267), followed by mesenteric ischemia (n=104), and surgical complications (n=62). Clinical Nutrition (2002) 21 (6): 515-520. Roux H, Chapelon E, Godart N. Epidemiology of anorexia nervosa: a review. Burden of eating disorders in 5-13-year-old children in Australia. A brief historical perspective has been added to better illustrate the center's growth and transformation. ScienceDirect is a registered trademark of Elsevier B.V. ScienceDirect is a registered trademark of Elsevier B.V. 2022, Journal of Parenteral and Enteral Nutrition, Clinical Nutrition, Volume 40, Issue 6, 2021, pp. 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. On single-stage analysis, the strongest correlations were noradrenaline dose at day 4 with GNG (R=0.71; P=0.0004) and Nutrition risk screening score (NRS) with EGP (R=0.42; P=0.05). Nutr Clin Pract. 314 patients (51.8%) died. Nurse estimated caloric intake was compared with digital before and after meal images. The American Society of Parenteral and Enteral Nutrition (ASPEN) has proposed the definition of refeeding syndrome shown below (32115791). Conversely, Akgul and colleagues [36] described a much shorter average time, 2.5days, that YP required NG before transitioning to an oral diet. occur in malnourished patients on refeeding following a period of starvation. https://doi.org/10.1002/erv.624. Nutr Clin Prac. Globally studies from North America [18, 21, 39, 41] and Turkey [36] focused on medical instability in YP with ED. 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. government site. Long-term effects of enteral feeding on growth and mental health in adolescents with anorexia nervosa--results of a retrospective German cohort study. 2016;58(6):6419. Although there are some RCTs examining aspects of NG use in YP with ED the majority of studies were retrospective cohorts or case series. Despite this, the patient encountered refeeding syndrome with significant electrolyte It offered the unique chance to present how to create and grow the IF center, increasing the quality of care. All authors assessed bias risk. https://doi.org/10.1515/ijamh-2014-0078. The majority of studies included were retrospective and based around case note reviews which are subjective and therefore likely to be biased. As a result, people at risk require medical supervision at a hospital or specialized facility. 2000;28(4):4705. (2014). 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. 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. Bri J Mental Health Nursing. Psychiatric nursing assistants views centred around: NG being an unpleasant practice, becoming sensitized or desensitized, and the importance of developing coping mechanisms to manage the distress. Nasogastric (NG) feeding use in YP with ED may be used as a lifesaving treatment when patients are physically unwell [7, 8]. An official website of the United States government. The catheter infection rate reached 0.39/1000 catheter days. Furthermore, no relevant association to lengths of stay in intensive care or hospital were detected. 69.) Supplemental nocturnal nasogastric refeeding for better short-term outcome in hospitalized adolescent girls with anorexia nervosa. 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. 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. Online Medical Education on Emergency Department (ED) Critical Care, Trauma, and Resuscitation. Neither of these guidelines are specific for children and adolescents. 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]. We investigated the occurrence of early RFH, its association with clinical outcome, and the impact of early parenteral nutrition (PN) on the development of early RFH in pediatric critical illness. Eur J Clin Nutr. The underlying health conditions that increase the risk of refeeding syndrome arent always preventable. A major cause of refeeding syndrome seems to be an endogenous insulin surge, which is triggered by carbohydrate intake. Fiber intake depends on age, gender, and sex. People who are at risk of heart-related complications may require heart monitoring. KH and CF performed search of databases and created the document. Terms & Conditions | Privacy Policy, Read recovery stories from ACUTE patients, See the latest research about conditions treated at ACUTE, Refeeding Syndrome Symptoms and Warning Signs, The Impact of Food Restriction on the Body, Endocrine Dysfunction in Anorexia Nervosa Patients, Complications from the Misuse of Laxatives and Diuretics, Avoidant Restrictive Food Intake Disorder (ARFID). Refeeding syndrome symptoms and warning signs typically appear early in the refeeding process, and require immediate medical intervention upon observation. 2014;68(2):1717. This is a secondary analysis of the PEPaNIC randomized controlled trial (N=1440), which showed that withholding supplemental parenteral nutrition (PN) for 1 week (late-PN) in the pediatric intensive care unit (PICU) accelerated recovery and reduced new infections compared to early-PN (<24h). Refeeding syndrome: Problems with definition and management. The pooled length of stay of 2965 patients with refeeding syndrome in 11 studies was 25.55 (95% CI, 20.2030.90) days. 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. The average length of stay in patients with refeeding syndrome was 25.55 days with a very high heterogeneity between studies. < 40%. Int J Adolesc Med Health. Kodua M, MacKenzie JM, Smyth N. Nursing assistants experiences of administering manual restraint for compulsory nasogastric feeding of young persons with anorexia nervosa. https://doi.org/10.1002/eat.1040. 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. JPEN J Parenter Enteral Nutr. As early RFH might impact recovery, it is important to closely monitor phosphate concentrations in patients, especially of those at risk for early RFH. Int J Eat Disord. A team with experience in gastroenterology and dietetics should oversee treatment. Nutrition (30) 1448-1455 No study discussed in detail the strategy used to transition from NG feeds back to an oral diet. Certain conditions, such as anorexia nervosa or chronic alcohol use disorder, can increase risk. Hindley, K., Fenton, C. & McIntosh, J. GNG at day 4 and EGP at day 10 could not be predicted with an e.c.
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nice guidelines refeeding syndrome 2021