nice guidelines refeeding syndrome 2021

Start vitamin B12 (cyanocobalamin) 1,000 micrograms orally twice daily. 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]. Patients with renal replacement therapy or unavailable phosphate concentrations were excluded from this analysis. Conversely, in MH wards, if NG has to be given under restraint, it may be required for a significant duration; in one study [46] the average was 170days. Three studies reported weight gain in the context of inadequate oral intake [9, 18, 39]. After electrolyte levels stabilize, increase caloric intake to 40 kCal/hr for a day, then increase to 60 kCal/hr for a day. encourage healthy eating and reaching a healthy body weight cover nutrition, cognitive restructuring, mood regulation, social skills, body image concern, self-esteem, and relapse prevention create a personalised treatment plan based on the processes that appear to be maintaining the eating problem Eighteen studies involving 3868 participants were included in our review. It's unclear whether IV thiamine is absolutely required here, or whether oral thiamine would be adequate. Maginot et al., 2017 [18] and Whitelaw et al., 2010 [9] reported NG bolus feeding in 13.8 and 15% in order to supplement oral diet with a mean weight gain of 3.1kgs and 2.6kgs respectively but did not report if this was specific to NG feeding. It offered the unique chance to present how to create and grow the IF center, increasing the quality of care. PubMedGoogle Scholar. Child and adolescent mental health service, Preferred Reporting Items for Systematic Reviews and Meta-Analyses, National Guideline Alliance (UK). 2014;68(2):1717. During the acute refeeding phase the need for weight restoration must be balanced against the risk of developing RS. A systematic review of enteral feeding by nasogastric tube in young people with eating disorders, https://doi.org/10.1186/s40337-021-00445-1, https://www.ncbi.nlm.nih.gov/books/NBK436876/, https://doi.org/10.1136/bmjopen-2018-027339, https://doi.org/10.1016/j.encep.2012.06.001, https://doi.org/10.7326/0003-4819-102-1-49, https://doi.org/10.1016/j.jadohealth.2009.11.207, https://doi.org/10.1186/s40337-016-0132-0, https://doi.org/10.1177/0148607106030003231, https://doi.org/10.1097/00004703-200412000-00005, https://doi.org/10.1017/S0033291714001573, https://doi.org/10.1016/j.jadohealth.2013.06.005, https://doi.org/10.1186/s40337-015-0047-1, https://doi.org/10.12968/bjmh.2019.8.3.124, https://doi.org/10.1136/archdischild-2016-310506, https://doi.org/10.1080/10640260902991236, https://doi.org/10.1007/s40519-018-0572-4, https://doi.org/10.24953/turkjped.2016.06.010, https://doi.org/10.1002/1098-108X(200012)28:4<470::AID-EAT18>3.0.CO;2-1, https://doi.org/10.1176/appi.ajp.159.8.1347, https://doi.org/10.5694/j.1326-5377.2009.tb02487.x, https://doi.org/10.1007/s00787-008-0706-8, http://creativecommons.org/licenses/by/4.0/, http://creativecommons.org/publicdomain/zero/1.0/. 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]. Eating Disorders: Recognition and Treatment. A blood test that reveals low levels of phosphorus, potassium or magnesium. In 2006, the National Institute for Health and Clinical Excellence (NICE) published a risk-assessment tool for the definition of the RFS risk [9]. This study aims to examine BG outcomes in the context of nutritional management during GC. This study aids the understanding of clinical nutrition strategies to prevent and treat refeeding syndrome. This study sought to (1) determine whether RFS, as operationalized in the 2020 American Society for Parenteral and Enteral Nutrition (ASPEN) guideline definition, is associated with adverse clinical outcomes and (2) identify key risk For example, insulin is a hormone that breaks down glucose (sugar) from carbohydrates. The search criteria was peer reviewed by a researcher from the University of Yorks Child and Adolescent Mental Health Intervention Centre. Article GC is delivered using a single model-based protocol (STAR), with default 4.48.0mmol/L target range via. 2013;39(2):8593. A comprehensive database search of AMED, EMBASE, APA Psychinfo and MEDLINE was performed with no language restriction from January 2000 to July 2020. Madden S, Morris A, Zurynski YA, Kohn M, Elliot EJ. Aggressive repletion of electrolytes, with the exception of calcium (IV calcium may exacerbate hypophosphatemia). Meal support therapy reduces the use of nasogastric feeding for adolescents hospitalized with anorexia nervosa. Search strategies combined keywords with controlled vocabulary terms (MeSH, Thesaurus); both quantitative and qualitative research were included. Early RFH occurred in 3% of critically ill children. Youve taken in little to no food for the past 5 or more consecutive days. Four databases were systematically searched until September 2020 for retrieving trials and observational studies. DOI: Lambers WM, et al. the contents by NLM or the National Institutes of Health. The risk of bias was deemed to be medium or high (see Additional file 1: Appendix 2) for the majority of the studies included due to the nature of their design, being case series or retrospective cohort studies. Increase of parenteral nutrition intake (in % kcal of predicted resting energy expenditure) decreased phosphate concentrations (c=0.002 (95% CI -0.002;0.001). 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. Maginot et al. Regulation of endogenous glucose production (EGP) is essential for glucose homeostasis. The anabolic processes require minerals and coenzymes such as thiamine [4,6]. This site represents our opinions only. https://doi.org/10.1007/s00787-008-0706-8. Four studies reported weight gain primarily in the context of ED YP with medical instability [24,25,26, 44]. Signs and symptoms are a superimposition of various electrolytic abnormalities and thiamine deficiency. We are the EMCrit Project, a team of independent medical bloggers and podcasters joined together by our common love of cutting-edge care, iconoclastic ramblings, and FOAM. Does aggressive refeeding in hospitalized adolescents with anorexia nervosa result in increased hypophosphatemia? NG feeding is a safe and efficacious method of increasing total calorie intake by either supplementing oral intake or continuously. To analyze the relationship of lengths of stay to muscle parameters, the competing risk approach introduced by Fine and Gray was applied. Given that the procedure can be painful [48] for YP and cause complications [29, 39], there is an urgent need for research exploring this wide variation in use of NG feeding to enable future direction and best practice guidance clinicians. There are clear risk factors for refeeding syndrome. Iolanda Cioffi: Conceptualization, Data curation, Methodology, Writing- Original draft preparation, Writing - Review & Editing. https://doi.org/10.7326/0003-4819-102-1-49. How to Gain Weight Fast: Tips to Be Safe and Healthy, Diabulimia: Why This Eating Disorder Is So Dangerous for People with Diabetes. Complications of refeeding syndrome can be prevented by electrolyte infusions and a slower refeeding regimen. The risk of bias was serious in 16 studies and moderate in the remaining 19. However, if the analysis was adjusted for confounders, e.g., Charlson Comorbidity Index, no relevant association regarding long-term survival was detected. Nevertheless, a bundle of variables could be identified to empirically assess the magnitude of both values. Burden of eating disorders in 5-13-year-old children in Australia. A systematic review and meta-analyses of literature, https://doi.org/10.1016/j.clnu.2021.04.023, ESPEN guideline on clinical nutrition in the intensive care unit, Restricted versus continued standard caloric intake during the management of refeeding syndrome in critically ill adults: a randomised, parallel-group, multicentre, single-blind controlled trial, Death resulting from overzealous total parenteral nutrition: the refeeding syndrome revisited, Refeeding syndrome in adults receiving total parenteral nutrition: an audit of practice at a tertiary UK centre, The risk of refeeding syndrome among severely malnourished tuberculosis patients in Chhattisgarh, India, Refeeding hypophosphataemia is more common in enteral than parenteral feeding in adult in patients, Incidence and outcome of refeeding syndrome in neurocritically ill patients, Impact of caloric intake in critically ill patients with, and without, refeeding syndrome: a retrospective study, Patients at risk of malnutrition: assessment of 11 cases of severe malnutrition with individualised total parenteral nutrition, COPD patients with acute exacerbation who developed refeeding syndrome during hospitalization had poor outcome: a retrospective cohort study, Refeeding syndrome in patients with gastrointestinal fistula, Management and prevention of refeeding syndrome in medical inpatients: an evidence-based and consensus-supported algorithm, Revisiting the refeeding syndrome: results of a systematic review, Early hypophosphatemia in critically ill children and the effect of parenteral nutrition: A secondary analysis of the PEPaNIC RCT, Impact of calorie intake and refeeding syndrome on the length of hospital stay of patients with malnutrition: a systematic review and meta-analysis, Psychiatric and medical comorbidities of eating disorders: findings from a rapid review of the literature, Evaluation of the ASPEN guidelines for refeeding syndrome among hospitalized patients receiving enteral nutrition: A retrospective cohort study, Refeeding Syndrome: A Critical Reality in Patients with Chronic Disease, Incidence and Impact of Refeeding Syndrome in an Internal Medicine and Gastroenterology Ward of an Italian Tertiary Referral Center: A Prospective Cohort Study, Short-chain fatty acids combined with intronic DNA methylation of. Couturier and Mahmood [29] highlighted that meal support therapy reduced the requirement for NG feeding from 66.7 to 11.1%, criteria for NG feeding was the same in both groups throughout and oral intake was encouraged. Bri J Mental Health Nursing. 2019;34(3):35970. 2017;5(1):110. (2008). Article 73 (12.04%) were successfully weaned off PN. Leeds and York Partnership NHS Foundation Trust, Mill Lodge, 520 Huntington Rd, York, YO32 9QA, UK, You can also search for this author in If you're underweight and looking to gain weight, it's very important to do it right. 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]. Exclusion terms: psychiatric disorders other than eating disorders; non-primary research; no outcomes specific to NG feeding and participants over 18years. Clinical adaptations/cohorts include variations on upper target (UL-9 with 9.0mmol/L, reducing workload and nutrition responsiveness), and insulin only (IO) with clinically set nutrition at 3 glucose concentrations (71g/L vs. 120 and 180g/L in the TARGET study). 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). Research is still needed to determine the best way to treat refeeding syndrome. 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]. 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], Some described NG feeds as easier than eating as it disguised the amount due to not swallowing; others felt it was a form of punishment for not gaining enough weight. This definition is somewhat unique in its incorporation of potassium and magnesium changes. Turk J Pediatr. In this cross-sectional study, we analyzed plasma SCFA levels, HIF3A expression, and CpG methylation of HIF3A intron 1 in peripheral blood from patients with type 2 diabetes presenting with (n=92) and without (n=105) cardiomyopathy. However, further research is required to assess the optimum NG feeding regime for YP at different levels of RS risk. There is no validated method to assess the retrospective and qualitative nature of studies included therefore we could not conduct a formal quality assessment or statistical method to evaluate the results. The incidence of RFS is at present uncertain due to heterogeneity of subjects involved and the lack of a universally accepted definition [3,4,7]. However, this will be the first systematic review on the use of NG feeding specifically in YP with ED. (2014). 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. 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. Refeeding syndrome results from underfeeding for a period of time, followed by re-initiation of nutritional support (including enteral nutrition, parenteral nutrition, or even IV dextrose). WebIf the patient is considered to be at high risk of refeeding syndrome, the following steps are advised by NICE:1 Start nutrition support at a maximum of 10 kcal/kg/day, increasing levels slowly to meet or exceed full needs by four to seven days. You have a history of alcohol use disorder or use of certain medications, such as insulin, chemotherapy drugs, diuretics, or antacids. The Charlson Comorbidity Index, however, was superior for preoperative risk stratification. In addition, refeeding often occurs alongside other serious conditions that typically require simultaneous treatment. J Dev Behav Pediatr. https://doi.org/10.1016/j.jadohealth.2013.06.005. It is not possible from this review to discern the advantages and disadvantages of each method as no study made a direct comparison. Refeeding is the process of reintroducing food after malnourishment or starvation. Although there are some RCTs examining aspects of NG use in YP with ED the majority of studies were retrospective cohorts or case series. 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). 2001;29(4):4418. Until a consensus definition is obtained, the following criteria seems reasonable: (29901461). Best C. How to set up and administer an enteral feed via a nasogastric tube. 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 2016;101(9):8368. (2011). This review aims to assess strategies for the use, tolerance and effectiveness of NG feeding in YP with restrictive ED. https://doi.org/10.1002/eat.22482. American Psychiatric Association. Three studies were qualitative interview studies, examining patient or staff feelings towards NG feeding in practice which increases the risk of confirmation bias. 2016;28(1):97105. 2 studies [21, 47] examined male only cohorts but both were high risk of bias. Refeeding with a lower calorie provision and a slow energy increase may be a better approach for severely malnourished patients with chronic comorbidity, while higher caloric intakes might be reserved for moderately malnourished patients with acute illnesses [ 69 ]. 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. Copyright 2009-. 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]. Rizzo SM, Douglas JW, Lawrence JC. Conversely the YP in Paccagnella and colleagues [20] research stated NG was helpful, particularly initially when an oral diet was challenging to manage. PubMed Sodium (salt) replacement may also be carefully monitored. When individuals who are at risk are identified early, treatments are likely to succeed. There are no other acknowledgements to be made. 2015;3(1):8. https://doi.org/10.1186/s40337-015-0047-1. 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 Glycaemic control (GC) may improve outcomes, though safe and effective control has proven elusive. https://doi.org/10.1038/ejcn.2013.244. J Human Nutr Dietetics. Weight loss of more than 10 percent of his or her body weight in the past 3 to 6 months; Little to no food for the past 5 or more consecutive days; or. Increasing awareness and using screening programs to identify those at risk of developing refeeding syndrome are the next steps in improving the outlook. The duration of underfeeding is typically >7-10 days. DOI: Mehanna HM, et al. Prevention is critical in avoiding the life-threatening complications of refeeding syndrome. 2019. 08-E012. British Dietetic Association. NG under restraint was described as causing distress and risk of injury to both staff and YP [48]. Neiderman et al [40] qualitative study describes patients time receiving NG varying from 1 to 476days (methods not explained). Predictive factors of length of inpatient treatment in anorexia nervosa. WebNephrotic syndrome . Food deprivation changes the way your body metabolizes nutrients. Rocks T, Pelly F, Wilkinson P. Nutritional management of anorexia nervosa in children and adolescent inpatients: the current practice of Australian dietitians. specialist registrar gastroenterology and clinical nutrition. 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). The site is secure. Glucose intolerance and insulin resistance manifest as hyperglycaemia in intensive care, which is associated with mortality and morbidities. As a result, people at risk require medical supervision at a hospital or specialized facility. Studies using bolus feeds stated that oral intake was encouraged and it was only when this was not fully achieved that supplementary NG was used [39]. 3729-3740, Clinical Nutrition, Volume 40, Issue 6, 2021, pp. Differences may be due to variable expertise of staff. Nocturnal nasogastric refeeding for hospitalized adolescent boys with anorexia nervosa. The evolution of all aspects of HPN is presented. Most studies tailored the calorie requirements to the individual patient, accounting for initial weight for height percentage and signs of medical instability. For more information about refeeding syndrome symptoms and warning signs, contact us. Both these pathways are dysregulated in acute stress, but the magnitude of this deregulation cannot be assessed in clinical practice. The novel associations between plasma butyric acid levels and HIF3A intron 1 methylation at CpG 6 may highlight an underlying mechanism by which the microbial-myocardial axis and hostmicrobe interactions may participate in the pathogenesis of DCM. By continuing you agree to the use of cookies. It is necessary to adapt to the changing circumstances. https://doi.org/10.1017/S0033291714001573. Inconsistent study results are partly caused by varying cut-off values used for defining sarcopenia. Most patients (96%) however present less severely with serum hypophosphataemia and no clinical signs [19]. As early RFH might impact recovery, it is important to closely monitor phosphate concentrations in patients, especially of those at risk for early RFH. Agostino and colleagues [23] delivered nutrition on a medical ward solely via NG for 14days before commencing oral diet in addition to NG feeding. 1. Nutr Clin Pract. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. However, this new definition may be insufficiently specific for clinically relevent electrolyte changes and requires clinical validation. Copyright 2023 Elsevier B.V. or its licensors or contributors. 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. Side effects are minimal but may include nasal bleeding or irritation, and imbalances in blood electrolytes which can be reduced by providing supplementation.

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