2001;29(4):4418. Figure1 displaying PRISMA flowchart of methodology utilised to search databases for this systematic review of enteral feeding in young people with restrictive eating disorders. 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]]. Nutr Clin Pract. In other words, the lower a patients weight, the higher their risk for this complication during refeeding. Additionally, the combination of plasma butyric acid levels and HIF3A intron 1 methylation at CpG 6 discriminated DCM patients from type2 diabetes mellitus (T2DM) patients. Eur Eat Disord Rev. Maginot TR, Kumar MM, Shiels J, Kaya W, Rhee KE. Careers, Unable to load your collection due to an error. CR168s Summary of Junior Marsipan: Management of really sick patients under 18 with Anorexia Nervosa. Death is often caused by cardiac abnormalities associated with extremely low bodyweight [6]. 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). Consequently, poor muscle status, determined by CT imaging, does not justify denying a patient an oncologic resection. The use of enteral nutrition in the treatment of eating disorders: a systematic review. WebRefeeding syndrome is defined as the potentially fatal shifts in fluids and electrolytes that may. Only 44% (8/19) of doctors compared with 70% (49/70) of dietitians followed the guidance. Nevertheless, a bundle of variables could be identified to empirically assess the magnitude of both values. 2005;13(4):26472. Its caused by sudden shifts in the electrolytes that help your The refeeding syndrome. 2017;22(5):26972. In addition, the incidence of RH was also assessed since it is considered the hallmark of the syndrome. Enteral nutrition via nasogastric tube for refeeding patients with anorexia nervosa: a systematic review. Fiber intake depends on age, gender, and sex. 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. The majority commenced on daily intake of less than 2000kcal and increased periodically. 2019. https://www.nice.org.uk/guidance/qs24. Supplemental nocturnal nasogastric refeeding for better short-term outcome in hospitalized adolescent girls with anorexia nervosa. Refeeding syndrome is caused by sudden shifts in the electrolytes that help your body metabolize food. Street K, Costelloe S, Wooton M, Upton S, Brough J. A variety of different feeding regimes were identified in this review which are summarised in Table2. 1985;102(1):4952. Hyperglycemia can induce the heart to enter an oxygen-restricted environment, which results in diabetic cardiomyopathy (DCM). However, this new definition may be insufficiently specific for clinically relevent electrolyte changes and requires clinical validation. 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). Valentina Ponzo: Data curation, Writing - Review & Editing. WebRefeeding syndrome consists of metabolic changes that occur on the reintroduction of nutrition to in those who are malnourished or in the starved state (Figure 1). Similar results were observed for the incidence of RH, which consistently varied across the studies. Risk of Refeeding Syndrome UHL Nutrition and Shifts in electrolyte levels can cause serious complications, including seizures, heart failure, and comas. DOI: hopkinsmedicine.org/gim/_pdf/consult/refeeding_syndrome.pdf, med.virginia.edu/ginutrition/wp-content/uploads/sites/199/2014/06/Parrish-September-16.pdf. https://doi.org/10.1097/00004703-200412000-00005. 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. 2023 BioMed Central Ltd unless otherwise stated. 2017;31(45):427. The incidence of refeeding syndrome is difficult to determine, as there isnt a standard definition. Skeletal muscle index (SMI), quantifying muscle mass, was assessed with computed tomography (CT) in 98 patients undergoing esophagectomy. Quality assessment, including risk of bias, was conducted by all authors. It is not possible from these studies to make any comparison between NG feeding and oral intake due to the confounding effect that for the vast majority of studies only high risk, medically unstable YP were considered for NG feeding. Patients randomized to late-PN had a lower chance of developing early RFH, which may be explained by the more gradual build-up of nutrition. https://doi.org/10.7748/ns.2017.e10509. Refeeding Syndrome Guideline GC is delivered using a single model-based protocol (STAR), with default 4.48.0mmol/L target range via. What Is Imitation Crab and Should You Eat It? Any discussion on the risks of the refeeding syndrome should include the increased threat of infection that may often be silent in malnutrition. 2018;33(6):7905. In 2006, the National Institute for Health and Clinical Excellence (NICE) published a risk-assessment tool for the definition of the RFS risk [9]. 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. Anorexia nervosa. 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. Medical wards used continuous feeding more frequently than MH wards, however this tended to be for a short period of time while the YP was medically unstable, after this they would be transitioned to an oral diet [22, 23, 25, 26]. https://doi.org/10.1093/pch/pxx063. Neiderman M, Zarody M, Tattersall M, Lask B. Enteric feeding in severe adolescent anorexia nervosa: a report of four cases. 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. Google Scholar. None developed clinical RFS. Copyright 2023 Elsevier B.V. or its licensors or contributors. Later, diagnostic criteria and algorithms for the RFS diagnosis based on both electrolyte abnormalities and clinical manifestations have been proposed [5,10,11]. An official website of the United States government. Guidelines help identify patients at elevated risk for developing this life-threatening complication of reintroducing calories in the early stages of anorexia nervosa treatment. 2015;3(1):8. https://doi.org/10.1186/s40337-015-0047-1. NG feeding involves a fine bore tube passed via the nasal passage into the stomach in order to administer nutrition. 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. The most common symptoms are as follows: Unfortunately, there is no uniform definition of refeeding syndrome. J Dev Behav Pediatr. Table1 includes a summary of included studies. There are many vegan protein powders on the market, with a variety of flavors and ingredients available. The most common primary disease was cancer (n=267), followed by mesenteric ischemia (n=104), and surgical complications (n=62). Long-term effects of enteral feeding on growth and mental health in adolescents with anorexia nervosa--results of a retrospective German cohort study. WebBACKGROUND. However, refeeding is also a critical component to recovery and NG feeding will often be utilised if a young person has been unable to manage oral intake in order to prevent signs of physical unwellness [9, 10]. Refeeding Syndrome: Definition, Treatment, Risks, and More https://doi.org/10.5694/j.1326-5377.2009.tb02487.x. Madden S, Miskovic-Wheatley J, Wallis A, et al. Aggressive repletion of electrolytes, with the exception of calcium (IV calcium may exacerbate hypophosphatemia). Rhabdomyolysis can occur (causing an elevated creatinine kinase). It comes after a rigorous review process. Youve taken in little to no food for the past 5 or more consecutive days. There is no high-quality evidence on this. The flowchart relative to the selection process is reported in Fig. Overall, 39% (57/146) of all responders thought the guidance represented safe practice, whereas 36% (53/146) thought they were excessively cautious. Results imply modulation of nutrition alongside insulin improves GC, particularly in patients with persistent hyperglycaemia/low glucose tolerance. Most studies tailored the calorie requirements to the individual patient, accounting for initial weight for height percentage and signs of medical instability. 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. This leads to another condition called hypophosphatemia (low phosphate). Nutrition (30) 1448-1455 https://doi.org/10.1002/eat.1040. Conversely, Akgul and colleagues [36] described a much shorter average time, 2.5days, that YP required NG before transitioning to an oral diet. Kezelman S, Crosby RD, Rhodes P, Hunt C, Anderson G, Clarke S, et al. 2000;28(4):4705. Perhaps carbohydrates should initially be limited to <40% of the total energy intake. Until recently, refeeding syndrome (RFS) has lacked standardized diagnostic criteria. 2009;17(4):32732. 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 Signs and symptoms are a superimposition of various electrolytic abnormalities and thiamine deficiency. 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, Refeeding prevention/monitoring package This is for at-risk patients, including: Substance or EtOH use. 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]. Couturier J, Mahmood A. Moreover, refeeding syndrome is seems to be associated with increased 6 months mortality [15]. ssslideshare.com This consensus definition is additionally intended to be used as a basis for further research into the incidence, consequences, pathophysiology, avoidan https://doi.org/10.1016/j.jadohealth.2013.06.005. Eat Weight Disord. Cookies policy. (2014). For example, insulin is a hormone that breaks down glucose (sugar) from carbohydrates. 29002-0025.) Our study suggests more standardized methods of caloric intake are needed in resource-limited settings with high co-prevalence of PEM and TB. Refeeding Protocol in Anorexia Nervosa Re-examined Use of High Protein Feeds in Refeeding Syndrome Studies published in languages other than English were translated prior to being reviewed. Start vitamin B12 (cyanocobalamin) 1,000 micrograms orally twice daily. Attitudes to NICE guidance on refeeding syndrome The primary physiologic problems are deficiencies of thiamine, phosphate, magnesium, and potassium (especially phosphate). https://doi.org/10.1007/s40519-018-0572-4. Royal Australian and new Zealand College of Psychiatrists clinical practice guidelines for the treatment of eating disorders. Marianna Pellegrini: Data curation, Writing - Review & Editing. However, due to the high heterogeneity of data, summary incidence measures are meaningless. https://doi.org/10.1002/erv.624. Sodium (salt) replacement may also be carefully monitored. Healthline Media does not provide medical advice, diagnosis, or treatment. Springer Nature. NG feeding is an important aspect of treatment for YP with ED who are medically unstable and/or unable to manage an adequate oral diet. When NG feeding is used under restraint bolus feeds are preferred due to concerns around the tube being removed by the YP once restraint had ceased [45]. 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. the refeeding syndrome. A systematic Manage cookies/Do not sell my data we use in the preference centre. Inpatients were prospectively enrolled. 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], Refeeding is the process of reintroducing food after malnourishment or starvation. A new riskassessment model was developed; nevertheless, further validation https://doi.org/10.1002/eat.22482. It's unclear whether IV thiamine is absolutely required here, or whether oral thiamine would be adequate. 3708-3717, Clinical Nutrition, Volume 40, Issue 6, 2021, pp. KH and CF performed search of databases and created the document. 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. Three studies were qualitative interview studies, examining patient or staff feelings towards NG feeding in practice which increases the risk of confirmation bias. The studies were analysed for risk of bias independently by CF, KH and JM. Strik Lievers L, Curt F, Wallier J, Perdereau F, Rein Z, Jeammet P, et al. Routine NG feeding may allow greater initial caloric intake, which does not increase risk of medical complications, and may actually increase initial weight gain thus reducing time in hospital. Rizzo SM, Douglas JW, Lawrence JC. Clinical Nutrition (2002) 21 (6): 515-520. Heres How Much Protein You Need in a Day to Build Muscle, changes in fat, glucose, or protein metabolism. Despite this, the patient encountered refeeding syndrome with significant electrolyte 1. Reduce the caloric intake to 20 kCal/hr for at least two days. (2016). Regulation of endogenous glucose production (EGP) is essential for glucose homeostasis. 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. To diagnose RFH most studies have used the occurrence of hypophosphatemia or a drop in serum/plasma phosphate after reintroduction of nutrition [11]. A number of YP in MH wards required restraint to NG feed with one study reporting this was required for 66% of YP [24]. (2008). To keep this page small and fast, questions & discussion about this post can be found on another page here. Best C. How to set up and administer an enteral feed via a nasogastric tube. Recent guidance from the British Dietetic Association [14] for NG feeding under restraint advised 12 bolus feeds per day even in those with high risk of refeeding syndrome (RS); it also concluded further research into this area was required. 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). To examine the impact of nutritional intake on phosphate concentrations, structural nested mean models with propensity score and censoring models were used. NICE CG32 Refeeding Guidelines: Retrospective audit To date, there is still no consensus regarding the RFS definition, and its incidence is therefore difficult to obtain. Thiamine (e.g., 500 mg IV q8hr, if mental status changes). 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. A total of 1247 patients were eligible (618 early-PN, 629 late-PN). For more information about refeeding syndrome symptoms and warning signs, contact us. (2011). However, it typically follows a period of: Certain conditions may increase your risk for this condition, including: Certain surgeries may also increase your risk. No unequivocal policy on how to start and progress with HPN has ever been presented. 2009;18(2):7584. EMCrit is a trademark of Metasin LLC. 2017;5(1):110. 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