Outcomes of a rapid refeeding protocol in Adolescent Anorexia Nervosa

Journal of Eating Disorders

Michael R Kohn³  Phillipa Hay¹  Stephen Touyz⁴  Simon Clarke³  Jane Miskovic-Wheatley²  Sloane Madden² 

[1] School of Medicine, University of Western Sydney, Sydney, Australia;Westmead Clinical School, The Sydney Children’s Hospitals Network, Westmead Campus, Sydney, Australia;Centre for Research into AdolescentS’ Health (CRASH), University of Sydney, Sydney, Australia;Clinical Psychology Unit, University of Sydney, Sydney, Australia

关键词: Rapid refeeding;    Nasogastric refeeding;    Adolescents;    Refeeding syndrome;    Inpatient treatment;    Eating disorder;    Anorexia Nervosa;   

Others  :  1149607
DOI  :  10.1186/s40337-015-0047-1

 received in 2014-11-12, accepted in 2015-02-28,  发布年份 2015

【 摘 要 】

Background

The impact of severe malnutrition and medical instability in adolescent Anorexia Nervosa (AN) on immediate health and long-term development underscores the need for safe and efficient methods of refeeding. Current refeeding guidelines in AN advocate low initial caloric intake with slow increases in energy intake to avoid refeeding syndrome. This study demonstrates the potential for more rapid refeeding to promote initial weight recovery and correct medical instability in adolescent AN.

Methods

Seventy-eight adolescents with AN (12–18 years), hospitalised in two specialist paediatric eating disorder units, for medical instability (bradycardia, hypotension, hypothermia, orthostatic instability and/or cardiac arrhythmia) were followed during a 2.5 week admission. Patients were refed using a standardised protocol commencing with 24–72 hours of continuous nasogastric feeds (ceased with daytime medical stability) and routine oral phosphate supplementation, followed by nocturnal feeds and a meal plan of 1200-2400 kcal/day aiming for a total caloric intake of 2400–3000 kcal/day. Along with indicators of medical stability, weight, phosphate and glucose levels were recorded.

Results

All patients gained weight in week one (M = 2.79 kg, SD = 1.27 kg) and at subsequent measurement points with an average gain of 5.12 kg (SD = 2.96) at 2.5 weeks. No patient developed hypophosphatemia, hypoglycaemia, or stigmata of the refeeding syndrome.

Conclusions

The refeeding protocol resulted in immediate weight gain and was well tolerated with no indicators of refeeding syndrome. There were no significant differences in outcomes between the treatment sites, suggesting the protocol is replicable.

Trial registration

Australian Clinical Trials Register number:ACTRN012607000009415 webcite

【 授权许可】

   
2015 Madden et al.; licensee BioMed Central.

【 图 表 】

Figure 1.

Figure 2.

【 参考文献 】

• [1]American Psychiatric Association: Treatment of patients with eating disorders (3rd ed.) Am J Psychiat 2006, 163(7 Suppl):4-54.
• [2]Beumont PJ, Large M: Hypophosphatemia, delirium and cardiac arrhythmia in anorexia nervosa. Med J Australia 1991, 155(8):519-22.
• [3]Golden ND, Katzman DK, Kreipe RE, Stevens SL, Sawyer SM, Rees J, et al.: Eating disorders in adolescents: position paper of the society for adolescent medicine. J Adolesc Health 2003, 33(6):496-503.
• [4]Gentile MG, Pastorelli P, Ciceri R, Manna G, Collimedaglia S: Specialized refeeding treatment for anorexia nervosa patients suffering from extreme undernutrition. Clin Nutr 2010, 29(5):627-32. doi: 10.1016/j.clnu.2010.03.008
• [5]Rocks T, Pelly F, Wilkinson P: Nutrition therapy during initiation of refeeding in underweight children and adolescent inpatients with anorexia nervosa: a systematic review of the evidence. J Acad Nutr Diet 2014, 114(6):897-907. doi: 10.1016/j.jand.2013.11.022
• [6]National Collaborating Centre for Mental Health (2004): Eating disorders: Core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders. NICE Clinical Guidelines, No. 9. British Psychological Society, Leicester, UK; 2004.
• [7]Hay P, Chinn D, Forbes D, Madden S, Newton R, Sugenor L, et al.: Royal Australian and New Zealand College of Psychiatrists clinical practice guidelies for the treatment of eating disorders. Aust N Z J Psychiatry 2014, 48:997-1009. doi: 10.1177/0004867414555814
• [8]Kohn MR, Madden S, Clarke S: Refeeding in anorexia nervosa: increased safety and efficiency through understanding the pathophysiology of protein calorie malnutrition. Curr Opin Pediatr 2011, 23(4):390-4. doi: 10.1097/MOP.0b013e3283487591
• [9]Weinsier R, Krumdieck C: Death resulting from overzealous total parenteral nutrition: the refeeding syndrome revisited. Am J Clin Nutr 1981, 34(3):393-9.
• [10]Sheridan PH, Collins M: Potentially life-threatening hypophosphatemia in anorexia nervosa. J Adolesc Health Care 1983, 4(1):44-6. doi: 10.1016/S0197-0070(83)80228-9
• [11]Schoken D, Holloway J: Weight loss and the heart: effects of anorexia nervosa and starvation. Arch Intern Med 1989, 149(4):877-81. doi: 10.1001/archinte. 1989.00390040085017
• [12]Kohn MR, Golden NH, Shenker IR: Cardiac arrest and delirium: presentations of the refeeding syndrome in severely malnourished adolescents with anorexia nervosa. J Adolesc Health 1998, 22(3):239-43. doi: 10.1016/S1054-139X(97)00163-8
• [13]Ornstein RM, Golden N, Jacobson MS, Shenker IR: Hypophosphatemia during nutritional rehabilitation in anorexia nervosa: implications for refeeding and monitoring. J Adolesc Health 2003, 32(1):83-8. doi: 10.1016/S1054-139X(02)00456-1
• [14]O’Connor G, Goldin J: The refeeding syndrome and glucose load. Int J Eat Disord 2010, 44:182-5. doi: 10.1002/eat.20791
• [15]Whitelaw M, Gilbertson H, Lam P-Y, Sawyer S: Does aggressive refeeding in hospitalized adolescents with anorexia nervosa result in increased hypophospataemia? J Adolesc Health 2010, 46(6):577-82. doi: 10.1016/j.jadohealth.2009.11.207
• [16]Gniuli DE, Liverani E, Capristo E, Greco A, Mingrone G: Blunted glucose metabolism in anorexia nervosa. Metabolism 2001, 50(8):876-81. doi: 10.1053/meta.2001.24915
• [17]Yasuhara D, Naruo T, Nagai N, Muranaga T, Nakhara T, Tanaka M, et al.: Glucose tolerance predicts short-term refeeding outcome in females with anorexia nervosa. Psychosom Med 2005, 67(4):669-76.
• [18]Kinzig KJ, Coughlin JW, Redgrave GW, Moran T, Guarda A: Insulin, glucose, and pancreatic polypeptide responses to a test meal in restricting type anorexia nervosa before and after weight restoration. Am J Physiol Endocrinol Metab 2007, 292(5):E1441-6. doi: 10.1152/ajpendo.00347.2006
• [19]Hart S, Abraham S, Luscombe G, Russell J: Eating disorder management in hospital patients: current practice among dietitians in Australia. Nutr Diet 2008, 65(1):16-22. doi: 10.1111/j.1747-0080.2007.00174.x
• [20]Hart S, Abraham S, Franklin R, Russell J: Weight changes during inpatiet refeeding of underweight eating disorder patients. Eur Eat Disord Rev 2011, 19(5):390-7. doi: 10.1002/erv.1052
• [21]Garber AK, Michihata N, Hetnal K, Shafer M, Mosicki A: A prospective examination of weight gain in hospitalized adolescents with anorexia nervosa on a recommended refeeding protocol. J Adolesc Health 2012, 50(1):24-9. doi: 10.1016/j.jadohealth.2011.06.011
• [22]Garber AK, Mauldin K, Michihata N, Buckelew S, Shafer MA, Moscicki AB: Higher calorie diets increase rate of weight gain and shorten hospital stay in hospitalized adolescents with anorexia nervosa. J Adolesc Health 2013, 53(5):579-84. doi: 10.1016/j.jadohealth.2013.07.014
• [23]Golden NH, Keane-Miller C, Sainani KL, Kapphahn CJ: Higher caloric intake in hospitalized adolescents with anorexia nervosa is associated with reduced length of stay and no increased rate of refeeding syndrome. J Adolesc Health 2013, 53(5):573-8. doi: 10.1016/j.jadohealth.2013.05.014
• [24]Agostino H, Erdstein H, Di Meglio G: Shifting paradigms: continuous nasogastric feeding with high caloric intakes in anorexia nervosa. J Adolesc Health 2013, 53(5):590-4. doi: 10.1016/j.jadohealth.2013.06.005
• [25]Leclerc A, Turrini T, Sherwood K, Katzman DK: Evaluation of a nutrition rehabilitation protocol in hospitalized adolescents with restrictive eating disorders. J Adolesc Health 2013, 53(5):585-9. doi: 10.1016/j.jadohealth.2013.06.001
• [26]Halse CD, Boughtwood D, Clarke S, Honey A, Kohn MR, Madden S: Illuminating multiple perspectives: meanings of nasogastric feeding in anorexia nervosa. Eur Eat Disord Rev 2005, 13(4):264-72. doi: 10.1002/erv.624
• [27]Madden S, Miskovic-Wheatley J, Wallis A, Kohn M, Lock J, Le Grange D, et al.: A randomised controlled trial of inpatient treatment for anorexia nervosa in medically unstable adolescents. Psychol Med 2014, First View:1-13. doi: 10.1017/S0033291714001573
• [28]American Psychiatric Association: Diagnostic and statistical manual of mental disorders (4th ed, text rev.). American Psychatric Association, Washington, DC; 2000.
• [29]American Psychiatric Association: Diagnostic and statistical manual of mental disorders (5th ed.). American Psychatric Association, Arlington, VA; 2013.
• [30]Fairburn C, Beglin S: The assessment of eating disorders: interview or self-report questionnaire? Int J Eat Disorder 1994, 16(4):363-70. doi: 10.1002/1098-108X(199412)16:4<363::AID-EAT2260160405>3.0.CO;2-#
• [31]Goldschmidt AB, Doyle AC, Wilfley DE: Assessment of binge eating in overweight youth using a questionnaire version of the child eating disorder examination with instructions. Int J Eat Disorder 2007, 40(5):460-7. doi: 10.1002/eat.20387
• [32]Bryant-Waugh RJ, Cooper PJ, Taylor CL, Lask BD: The use of the eating disorder examination with children: a pilot study. Int J Eat Disorder 1996, 19(4):391-7. doi: 10.1002/(SICI)1098-108X(199605)19:4<391::AID-EAT6>3.0.CO;2-G
• [33]Kuczmarski RC, Ogden CL, Guo SS, Grummer-Strawn L, Flegal K, Mei Z, et al.: 2000 growth charts for the United States: Methods and development. 246th edition. 2002.
• [34]Le Grange D, Doyle PM, Swanson SA, Ludwig K, Glunz C, Kreipe RE: Calculation of expected body weight in adolescents with eating disorders. Pediatrics 2012, 129(2):438-46. doi: 10.1542/peds. 2011-1676
• [35]Couturier J, Lock J: What is recovery in adolescent anorexia nervosa? Int J Eat Disord 2006, 39(7):550-5. doi: 10.1002/eat.20309
• [36]Haas VK, Allen JR, Kohn MR, Clarke SD, Zhang S, Briody JN, et al.: Total body protein in healthy adolescent girls: validation of estimates derived from simpler measures with neutron activation analysis. Am J Clin Nutr 2007, 85(1):66-72.
• [37]Haas VK, Kohn MR, Clarke SD, Allen JR, Madden S, Muller MJ, et al.: Body composition changes in female adolescents with anorexia nervosa. Am J Clin Nutr 2009, 89(4):1005-10. doi: 10.3495/ajcn.2008.26958
• [38]Kreitzman SN, Coxon AY, Szaz KF: Glycogen storage: illusions of easy weight loss, excessive weight regain, and distortions in estimates of body composition. Am J Clin Nutr 1992, 56(1 Suppl):292S-3.
• [39]King RF, Cooke C, Carroll S, O’Hara J: Estimating changes in hydration status from changes in body mass: considerations regarding metabolic water and glycogen storage. J Sports Sci 2008, 26(12):1361-3. doi: 10.1080/02640410802192768
• [40]Robb AS, Silber TJ, Orrell-Valente JK, Valadez-Meltzer A, Ellis N, Dadson MJ, et al.: Supplemental nocturnal nasogastric refeeding for better short-term outcome in hospitalized adolescent girls with anorexia nervosa. Am J Psychiatry 2002, 159(8):1347-53. doi: 10.1176/appi.ajp.159.8.1347
• [41]Imbierowicz K, Braks K, Jacoby GE, Geiser F, Conrad R, Schilling G, et al.: High-caloric supplements in anorexia treatment. Int J Eat Disord 2002, 32(2):135-45. doi: 10.1002/eat.10085
• [42]Redgrave GW, Coughlin JW, Schreyer CC, Martin LM, Leonpacher AK, Seide M, et al. Refeeding and weight restoration outcomes in anorexia nervosa: challenging current guidelines. Int J Eat Disord. 2015. doi: 10.1002/eat.22390.