A Specialized Refeeding Program for Those with Severe Anorexia Nervosa

A specialized and flexible program helped avoid the refeeding syndrome.

Refeeding severely malnourished anorexia nervosa (AN) patients nearly always involves a delicate balance between two complex and conflicting tasks: first, avoiding the “refeeding syndrome,” caused by correcting malnutrition too quickly, and second, evading “underfeeding,” caused by taking a too-slow or too-cautious approach to restoring nutrition and weight.

Dr. Maria Gabriella Gentile and co-workers at the Eating Disorders Unit, Niguarda Hospital, Milan, Italy, recently reported the case of a 24-year-old woman admitted to their unit with extreme under-nutrition (body mass index, or BMI, of 9.6 kg/m²). With a specialized nutritional program and careful monitoring of vital signs and laboratory values, the patient doubled her body weight within a 3-month period without developing the refeeding syndrome (Clinical Medicine Insights 2013:6:51).

To avoid the risk of overfeeding, the authors measured the patient’s resting metabolic rate (REE) continuously, starting at admission. They then used indirect calorimetric measurements to establish caloric intake. The patient’s weight was monitored daily, and bed rest was strictly organized and monitored. To avoid fluid overload and to reduce gastric discomfort, a commercial polymeric, lactose-free gluten-free high-calorie (2 kcal/mL) high-nitrogen (17%), completely fluid formula was chosen for the patient. Oral fluids were restricted to 1000 mL/day for the first month, and then progressively increased to 1500 mL/day. The patient also was given 24-hour nasogastric tube feeding, using feeding pumps to reduce gastric discomfort. Caloric intake was gradually increased according to clinical results (beginning with the increase of body weight) and according to REE measurements taken every month during the first 120 days. Weight was monitored daily.

A combination of enteral nutrition and increased oral feeding

Dr. Gentile and colleagues’ approach was to follow the REE while using enteral nutrition feeding and to aid anabolic rebuilding by increasing amounts of oral feeding. Nasogastric enteral feeding was stopped after 75 days of treatment. For the next 45 days the oral diet was augmented with oral liquid supplements.    To prevent hypophosphatemia, the authors closely monitored serum phosphate levels during early refeeding, rather than simply measuring this once at the beginning of refeeding. During the refeeding period, the patient’s electrolyte levels, especially the plasma phosphate level, were checked nearly every day during the first weeks. During the first 2 weeks, 5000 to 6000 mg of phosphate was provided each day.

Team dietitians encouraged (but did not force) the patient to start eating again, and each meal was supervised by dietitians and/or nurses. Oral caloric intake started with 260 kcal/day and after a week was increased to 800 kcal/day (protein: 45 gm/day). After a month, this was increased to 1260 kcal/day (protein: 59 gm/day). At the end of the second month of treatment, the oral caloric intake reached 1850 kcal/day (protein: 61 gm/day). To help control anxiety and obsessive-compulsive symptoms, the patient also was treated with diazepam (1 mg/day to start, reaching 3 mg/day) and haloperidol (beginning at 1 mg/day and reaching 2 mg/day), with psychotherapy.

After approximately 3 months, the patient’s body weight doubled, and her BMI and all lab values normalized. The researchers reported no major signs or symptoms or refeeding and pressure ulcers were prevented by changing the patient’s position and using a special fluidized bed.    The patient agreed to continue treatment as a day hospital patient. After 6 months from the beginning of care, her menses resumed, and body weight was normal.

A specialized unit and multidisciplinary team are essentials

Dr. Gentile and colleagues noted that when refeeding is started in such severely malnourished patients, it is mandatory to supplement oral, enteral, and/or intravenous phosphate and other electrolytes, such as potassium and magnesium, and it may be necessary to measure the serum levels daily during the first stage of refeeding.    They chose a caloric intake about three times that often recommended because of their belief that such extremely undernourished patients need at least that level to match the measured REE. Finally, they recommend treating such high-risk patients in “a specialized unit with a multidisciplinary team that has a clear and flexible treatment plan.”