Outcomes of an Inpatient Refeeding Protocol in Youth with Anorexia Nervosa: Rady Children's Hospital San Diego/University of California, San Diego

By Maginot, Tamara R.; Kumar, Maya M. et al. | Journal of Eating Disorders, January 3, 2017 | Go to article overview

Outcomes of an Inpatient Refeeding Protocol in Youth with Anorexia Nervosa: Rady Children's Hospital San Diego/University of California, San Diego


Maginot, Tamara R., Kumar, Maya M., Shiels, Jacqueline, Kaye, Walter, Rhee, Kyung E., Journal of Eating Disorders


Author(s): Tamara R. Maginot[sup.1], Maya M. Kumar[sup.2], Jacqueline Shiels[sup.1], Walter Kaye[sup.1] and Kyung E. Rhee[sup.2,3]

Plain english summary

Refeeding syndrome is a concern for patients with eating disorders who are undergoing nutritional rehabilitation. It is traditionally recommended to start at a lower calorie level and advance slowly as the safest means of treatment. However, in this sample of 87 patients with restrictive eating disorders hospitalized with medical complications of malnutrition at Rady Children's Hospital, San Diego/University of California San Diego, starting at a higher calorie level was not associated with an increased risk of electrolyte abnormalities. However, patients presenting at <75% of expected body weight were at increased risk of developing hypophosphatemia regardless of initial calorie level. Further research is needed to determine if this method of calorie advancement is truly safe in patients with severe malnutrition (i.e., those <75% of expected body weight).

Background

In managing patients with moderate to severe malnutrition secondary to restrictive eating disorders, the optimal rate of nutritional rehabilitation remains a subject of debate. Guidelines by the American Psychiatric Association [1] and Academy of Nutrition and Dietetics [2] currently recommend a conservative approach to nutritional rehabilitation to prevent refeeding syndrome. Refeeding syndrome occurs when malnourished patients transition to using dietary carbohydrates rather than stored macronutrients as their primary source of energy [3-5]. As the body shifts from a chronically catabolic state to an anabolic state, low body stores of phosphorus, magnesium, and potassium, in conjunction with intracellular shifting of these electrolytes (a consequence of an exaggerated insulin response) leads to low serum electrolyte levels [3-5]. Clinical sequelae may be severe, including muscle weakness and cramping, cardiac arrhythmias, vomiting, seizures, delirium, and death [3-6]. Low calorie diets have traditionally been recommended to prevent this complication during weight restoration [1, 2]. However, this approach to refeeding increases the risk of providing inadequate nutrition to cover baseline energy expenditure and facilitate weight restoration [7, 8]. This may result in slow weight gain or even weight loss during the refeeding process, leading to prolonged medical complications related to malnutrition (e.g., bradycardia) and longer hospitalizations [7-10].

Recent research has examined whether a less conservative approach to nutritional rehabilitation can be safely performed, particularly in those with restrictive eating disorders [7-19]. Several groups have evaluated the effect of starting on a higher calorie diet (ranging from 1400 to 2400 kcals) among patients aged 10 to 21 years old and report shorter hospital stays [11, 13], faster weight gain [12-14], a low rate of developing hypophosphatemia during nutritional rehabilitation, and no incidence of clinical refeeding syndrome [8-15]. While rate of calorie advancement varied among groups, increasing 250 kcals on day 2 and 3, and then by 250 kcals every other day until day 7, was not associated with increased risk of electrolyte abnormalities and resulted in faster weight gain [14]. Many of these groups started patients on prophylactic phosphorus supplementation which may have helped prevent the development of electrolyte abnormalities or clinical refeeding syndrome [10, 12, 13]. The use of NG tubes for nutritional rehabilitation was also not associated with adverse outcomes [12, 16, 17]. Overall, these studies suggest that starting at a higher calorie level and advancing quickly may be considered in moderately malnourished (75-85% of expected body weight) adolescents and young adults with AN.

Unfortunately, there is limited literature on the safety of refeeding at higher calorie levels in severely malnourished patients with eating disorders. …

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