Balancing speed and safety.
Reprinted from Eating Disorders Review
January/February Volume 24, Number 1
©2013 Gürze Books
Severe under-nutrition affects every part of the body. Under-nutrition almost always causes marked changes in body spaces (for example, alterations of intra-extracellular water) and in body mass and composition. Two challenges face clinicians who are planning refeeding for severely malnourished eating disorder patients: (1) avoiding the refeeding syndrome, caused by correcting malnutrition too quickly, and (2) averting underfeeding caused by using a too-cautious approach to correcting malnutrition. Two recent studies underline the challenges of refeeding such patients.
Enteral feeding: avoiding risks of refeeding syndrome
In the first study, conducted at the Eating Disorders Unit at Niguarda Hospital, Milan, Italy, clinical nutritionist Maria Gabriella Gentile and her colleagues found that even in cases of extreme malnutrition, enteral feeding may be well tolerated. The researchers selected enteral nutrition (EN) because they felt that parenteral nutrition would place patients at higher risk of developing the refeeding syndrome. They also found that prophylactic phosphorus and potassium supplements given during the first weeks of refeeding were effective for gradual correction of very severe under-nutrition. Their study included 10 patients (mean age: 22 years) with a mean initial body mass index (BMI) of 11.2 kg/m2 (Nutrients. 2012; 4:1293). All patients presented with low blood pressure, apathy and irritability, reduced muscle size, hypothermia, and a clinically significant reduction in measured resting energy expenditure, or REE (-37.0%).
The author and her colleagues started nutritional therapy with 24-hour continuous supplementation, to reduce gastric discomfort, diarrhea, and metabolic alterations. Only when the under-nutrition was partially corrected did they gradually reduce the infusion time. Plasma electrolyte levels, especially phosphate, sodium, potassium and magnesium, glucose levels and other nutritional deficiencies were closely monitored and corrected during feeding.
For patients with life-threatening illness, immediate nutritional support with enteral nutrition was begun, using a low rate with temporary nasogastric feeding. Patients were closely monitored and regulated via an electronically operated pump. The group chose nasogastric feeding because it is a simple nonsurgical procedure. For patients who were not affected by a specific illness, such as renal or hepatic insufficiency, or diabetes, a high-nitrogen polymeric diet free of lactose and gluten was used. To reduce gastric discomfort and avoid fluid overload, a high-calorie formula (1.7-2.0 kcal/mL) was used. After 90 days of intensive inpatient treatment, the mean BMI increased from 11.2 kg/m2 to 17.3 kg/m2 and mean body weight rose from 27.9 kg to 43 kg.
Finally, the researchers also credited an empathetic approach by the entire multidisciplinary team for obtaining reasonable compliance and cooperation by patients; when needed, behavioral interventions and other types of psychotherapy were available for patients and their parents.
Mishandling refeeding: Two perplexing cases
A second report underscores the perplexing mishandling of some refeeding cases (Eat Disord. 2013; 21:81). Drs. Pauline Powers and N.L. Cloak at the Center for Eating and Weight Disorders at the University of South Florida, Tampa, reported that a 28-year-old woman with anorexia nervosa (AN) was sent to the emergency room by her gastroenterologist because of weakness and nausea following placement of a percutaneous endoscopic gastrostomy (PEG) tube, with a plan for hospital admission. The woman spent two days in the emergency department without receiving any nourishment and was discharged home after laboratory tests and x-ray studies were normal. After her gastroenterologist reviewed the x-rays, he determined that she had a bowel obstruction, and she was readmitted to the hospital. She weighed 2 kg less than on her original visit.
A 26-year-old woman with AN was prematurely discharged from a treatment facility with a Dobhoff feeding tube in her small intestine. She became dizzy and weak and was readmitted to the hospital but did not receive any feeding during the 6 days she was hospitalized, despite blood glucose levels in the 30s. An early order for tube feeding was cancelled for unknown reasons. Two days after discharge she again developed weakness and returned to the emergency department with a letter from her doctor stating that she needed medical supervision for the initiation of refeeding. Once more she was discharged from the emergency room within hours, only to be readmitted the next day.
The Italian authors noted that only a few studies have analyze the use of nutritional support among severely undernourished patients, and there is a real need for evidence-based guidelines for use of enteral or parenteral nutrition. One such effort was the “Evidence-Based Guidelines for Nutritional Support of the Critically Ill: Results of a Bi-National Guideline Development Conference,” an Australia-New Zealand collaborative project published in 2003 (www.EvidenceBased.net/files) .