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01-03-2019 | Clinical Algorithm

Refeeding in anorexia nervosa

Authors: Anne Bargiacchi, Julia Clarke, Anne Paulsen, Juliane Leger

Published in: European Journal of Pediatrics | Issue 3/2019

Abstract

Refeeding in anorexia nervosa is a collaborative enterprise involving multidisciplinary care plans, but clinicians currently lack guidance, as treatment guidelines are based largely on clinical confidence rather than more robust evidence. It seems crucial to identify reproducible approaches to refeeding that simultaneously maximize weight recovery and minimize the associated risks, in addition to improving long-term weight and cognitive and behavioral recovery and reducing relapse rates. We discuss here various approaches to refeeding, including, among others, where, by which route, how rapidly patients are best refed, and ways of choosing between them, taking into account the precautions or the potential effects of medication or of psychological care, to define better care plans for use in clinical practice.

Conclusion: The importance of early weight gain for long-term recovery has been demonstrated by several studies in both outpatient and inpatient setting. Recent studies have also provided evidence to support a switch in current care practices for refeeding from a conservative approach to higher calorie refeeding. Finally, the risks of undernutrition/“underfeeding syndrome” and a maintenance of weight suppression are now better identified. Greater caution should still be applied for more severely malnourished < 70% average body weight and/or chronically ill, adult patients.

What is Known:

• Refeeding is a central part of the treatment in AN and should be a multidisciplinary and collaborative enterprise, together with nutritional rehabilitation and psychological support, but there are no clear guidelines on the management of refeeding in clinical practice.

• The risk of a refeeding syndrome is well known and well managed in severely malnourished patients (“conservative approaches”).

What is New:

• There is evidence that early weight restoration has an impact on outcome, justifying an aggressive approach to refeeding in the early stages of the illness.

• The risks of “underfeeding syndrome” and of a maintenance of weight suppression are now better identified and there is sufficient evidence to support a switch in current care practices for refeeding from a conservative approach to higher calorie refeeding.

Yager J, Devlin MJ, Halmi KA, Herzog DB, Mitchell III JE, Powers P, Kathryn J, Zerbe KJ (2006) Treatment of patients with eating disorders, third edition. In: APA practice guidelines for the treatment of psychiatric disorders: comprehensive guidelines and guideline watches, 1st ed. American Psychiatric Association, Arlington, VA

Accurso EC, Ciao AC, Fitzsimmons-Craft EE, Lock JD, le Grange D (2014) Is weight gain really a catalyst for broader recovery?: the impact of weight gain on psychological symptoms in the treatment of adolescent anorexia nervosa. Behav Res Ther 56:1–6. https://doi.org/10.1016/j.brat.2014.02.006 CrossRefPubMedPubMedCentral

Agostino H, Erdstein J, Di Meglio G (2013) Shifting paradigms: continuous nasogastric feeding with high caloric intakes in anorexia nervosa. J Adolesc Health Off Publ Soc Adolesc Med 53:590–594. https://doi.org/10.1016/j.jadohealth.2013.06.005 CrossRef

Born C, de la Fontaine L, Winter B et al (2015) First results of a refeeding program in a psychiatric intensive care unit for patients with extreme anorexia nervosa. BMC Psychiatry 15:57. https://doi.org/10.1186/s12888-015-0436-7 CrossRefPubMedPubMedCentral

Brown CA, Sabel AL, Gaudiani JL, Mehler PS (2015) Predictors of hypophosphatemia during refeeding of patients with severe anorexia nervosa. Int J Eat Disord 48:898–904. https://doi.org/10.1002/eat.22406 CrossRefPubMed

Eating disorders: recognition and treatment | Guidance and guidelines | NICE. https://www.nice.org.uk/guidance/ng69. Accessed 5 Nov 2018

Garber AK (2017) A few steps closer to answering the unanswered questions about higher calorie refeeding. J Eat Disord 5:8. https://doi.org/10.1186/s40337-017-0139-1 CrossRefPubMedPubMedCentral

Garber AK, Michihata N, Hetnal K, Shafer MA, Moscicki AB (2012) A prospective examination of weight gain in hospitalized adolescents with anorexia nervosa on a recommended refeeding protocol. J Adolesc Health Off Publ Soc Adolesc Med 50:24–29. https://doi.org/10.1016/j.jadohealth.2011.06.011 CrossRef

Garber AK, Sawyer SM, Golden NH, Guarda AS, Katzman DK, Kohn MR, le Grange D, Madden S, Whitelaw M, Redgrave GW (2016) A systematic review of approaches to refeeding in patients with anorexia nervosa. Int J Eat Disord 49:293–310. https://doi.org/10.1002/eat.22482 CrossRefPubMed

10.

Gaudiani JL, Mehler PS (2016) Rare medical manifestations of severe restricting and purging: “Zebras,” missed diagnoses, and best practices. Int J Eat Disord 49:331–344. https://doi.org/10.1002/eat.22475 CrossRefPubMed

11.

Gaudiani JL, Sabel AL, Mehler PS (2014) Low prealbumin is a significant predictor of medical complications in severe anorexia nervosa. Int J Eat Disord 47:148–156. https://doi.org/10.1002/eat.22233 CrossRefPubMed

12.

Golden NH, Keane-Miller C, Sainani KL, Kapphahn CJ (2013) 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 Off Publ Soc Adolesc Med 53:573–578. https://doi.org/10.1016/j.jadohealth.2013.05.014 CrossRef

13.

Haute Autorité de Santé—Anorexie mentale: prise en charge. https://www.has-sante.fr/portail/jcms/c_985715/fr/anorexie-mentale-prise-en-charge. Accessed 6 Sep 2018

14.

Hay P, Chinn D, Forbes D, Madden S, Newton R, Sugenor L, Touyz S, Ward W, Royal Australian and New Zealand College of Psychiatrists (2014) Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of eating disorders. Aust N Z J Psychiatry 48:977–1008. https://doi.org/10.1177/0004867414555814 CrossRefPubMed

15.

Haynos AF, Snipes C, Guarda A, Mayer LE, Attia E (2016) Comparison of standardized versus individualized caloric prescriptions in the nutritional rehabilitation of inpatients with anorexia nervosa. Int J Eat Disord 49:50–58. https://doi.org/10.1002/eat.22469 CrossRefPubMed

16.

Herpertz-Dahlmann B (2017) Treatment of eating disorders in child and adolescent psychiatry. Curr Opin Psychiatry 30:438–445. https://doi.org/10.1097/YCO.0000000000000357 CrossRefPubMed

17.

Herpertz-Dahlmann B, Schwarte R, Krei M, Egberts K, Warnke A, Wewetzer C, Pfeiffer E, Fleischhaker C, Scherag A, Holtkamp K, Hagenah U, Bühren K, Konrad K, Schmidt U, Schade-Brittinger C, Timmesfeld N, Dempfle A (2014) Day-patient treatment after short inpatient care versus continued inpatient treatment in adolescents with anorexia nervosa (ANDI): a multicentre, randomised, open-label, non-inferiority trial. Lancet Lond Engl 383:1222–1229. https://doi.org/10.1016/S0140-6736(13)62411-3 CrossRef

18.

Herpertz-Dahlmann B, Seitz J, Baines J (2017) Food matters: how the microbiome and gut-brain interaction might impact the development and course of anorexia nervosa. Eur Child Adolesc Psychiatry 26:1031–1041. https://doi.org/10.1007/s00787-017-0945-7 CrossRefPubMedPubMedCentral

19.

Himmerich H, Treasure J (2018) Psychopharmacological advances in eating disorders. Expert Rev Clin Pharmacol 11:95–108. https://doi.org/10.1080/17512433.2018.1383895 CrossRef

20.

Khan LUR, Ahmed J, Khan S, Macfie J (2011) Refeeding syndrome: a literature review. Gastroenterol Res Pract 2011:1–6. https://doi.org/10.1155/2011/410971 CrossRef

21.

Le Grange D, Accurso EC, Lock J et al (2014) Early weight gain predicts outcome in two treatments for adolescent anorexia nervosa. Int J Eat Disord 47:124–129. https://doi.org/10.1002/eat.22221 CrossRefPubMed

22.

Lebow J, Sim LA, Accurso EC (2018) Is there clinical consensus in defining weight restoration for adolescents with anorexia nervosa? Eat Disord 26:270–277. https://doi.org/10.1080/10640266.2017.1388664 CrossRefPubMed

23.

Léger J, Fjellestad-Paulsen A, Bargiacchi A, Doyen C, Ecosse E, Carel JC, le Heuzey MF (2017) Can growth hormone treatment improve growth in children with severe growth failure due to anorexia nervosa? A preliminary pilot study. Endocr Connect 6:839–846. https://doi.org/10.1530/EC-17-0200 CrossRefPubMedPubMedCentral

24.

Leitner M, Burstein B, Agostino H (2016) Prophylactic phosphate supplementation for the inpatient treatment of restrictive eating disorders. J Adolesc Health Off Publ Soc Adolesc Med 58:616–620. https://doi.org/10.1016/j.jadohealth.2015.12.001 CrossRef

25.

Marikar D, Reynolds S, Moghraby OS (2016) Junior MARSIPAN (Management of Really Sick Patients with Anorexia Nervosa). Arch Dis Child Educ Pract Ed 101:140–143. https://doi.org/10.1136/archdischild-2015-308679 CrossRefPubMed

26.

Matthews K, Hill J, Jeffrey S, Patterson S, Davis A, Ward W, Palmer M, Capra S (2018) A higher-calorie refeeding protocol does not increase adverse outcomes in adult patients with eating disorders. J Acad Nutr Diet 118:1450–1463. https://doi.org/10.1016/j.jand.2018.01.023 CrossRefPubMed

27.

Mehler PS, Winkelman AB, Andersen DM, Gaudiani JL (2010) Nutritional rehabilitation: practical guidelines for refeeding the anorectic patient. J Nutr Metab 2010:1–7. https://doi.org/10.1155/2010/625782 CrossRef

28.

Mehler PS, Blalock DV, Walden K, Kaur S, McBride J, Walsh K, Watts J (2018) Medical findings in 1,026 consecutive adult inpatient-residential eating disordered patients. Int J Eat Disord 51:305–313. https://doi.org/10.1002/eat.22830 CrossRefPubMed

29.

Miller KK, Lee EE, Lawson EA, Misra M, Minihan J, Grinspoon SK, Gleysteen S, Mickley D, Herzog D, Klibanski A (2006) Determinants of skeletal loss and recovery in anorexia nervosa. J Clin Endocrinol Metab 91:2931–2937. https://doi.org/10.1210/jc.2005-2818 CrossRefPubMedPubMedCentral

30.

Narayanan V, Gaudiani JL, Mehler PS (2009) Serum albumin levels may not correlate with weight status in severe anorexia nervosa. Eat Disord 17:322–326. https://doi.org/10.1080/10640260902991202 CrossRefPubMed

31.

Norris ML (2016) Phosphate supplementation during refeeding of hospitalized adolescents with anorexia nervosa-watch and wait or empirically treat. J Adolesc Health Off Publ Soc Adolesc Med 58:593–594. https://doi.org/10.1016/j.jadohealth.2016.03.030 CrossRef

32.

Publications—Academy for Eating Disorders. https://www.aedweb.org/learn/publications/medical-care-standards. Accessed 6 Sep 2018

33.

Redgrave GW, Coughlin JW, Schreyer CC, Martin LM, Leonpacher AK, Seide M, Verdi AM, Pletch A, Guarda AS (2015) Refeeding and weight restoration outcomes in anorexia nervosa: challenging current guidelines. Int J Eat Disord 48:866–873. https://doi.org/10.1002/eat.22390 CrossRefPubMed

34.

Rigaud D, Pennacchio H, Bizeul C, Reveillard V, Vergès B (2011) Outcome in AN adult patients: a 13-year follow-up in 484 patients. Diabetes Metab 37:305–311. https://doi.org/10.1016/j.diabet.2010.11.020 CrossRefPubMed

35.

Rio A, Whelan K, Goff L, Reidlinger DP, Smeeton N (2013) Occurrence of refeeding syndrome in adults started on artificial nutrition support: prospective cohort study. BMJ Open 3:e002173. https://doi.org/10.1136/bmjopen-2012-002173 CrossRefPubMedPubMedCentral

36.

Robinson P, Rhys Jones W (2018) MARSIPAN: management of really sick patients with anorexia nervosa. BJPsych Adv 24:20–32. https://doi.org/10.1192/bja.2017.2 CrossRef

37.

Rosen E, Bakshi N, Watters A, Rosen HR, Mehler PS (2017) Hepatic complications of anorexia nervosa. Dig Dis Sci 62:2977–2981. https://doi.org/10.1007/s10620-017-4766-9 CrossRefPubMed

38.

Rozé C, Doyen C, Le Heuzey M-F et al (2007) Predictors of late menarche and adult height in children with anorexia nervosa. Clin Endocrinol 67:462–467. https://doi.org/10.1111/j.1365-2265.2007.02912.x CrossRef

39.

Shepherd S, Kyriakou A, Shaikh MG, McDevitt H, Oakley C, Thrower M, Ahmed SF, Mason A (2018) Longitudinal changes in bone parameters in young girls with anorexia nervosa. Bone 116:22–27. https://doi.org/10.1016/j.bone.2018.03.022 CrossRefPubMed

40.

Swenne I, Parling T, Salonen Ros H (2017) Family-based intervention in adolescent restrictive eating disorders: early treatment response and low weight suppression is associated with favourable one-year outcome. BMC Psychiatry 17:333. https://doi.org/10.1186/s12888-017-1486-9 CrossRefPubMedPubMedCentral

41.

Troubles des conduites alimentaires de l’enfant et de l’adolescent - 9782294748783 | Elsevier Masson—Livres, ebooks, revues et traités EMC pour toutes spécialités médicales et paramédicales. https://www.elsevier-masson.fr/troubles-des-conduites-alimentaires-de-lenfant-et-de-ladolescent-9782294748783.html. Accessed 6 Sep 2018

Title: Refeeding in anorexia nervosa
Authors: Anne Bargiacchi
Julia Clarke
Anne Paulsen
Juliane Leger
Publication date: 01-03-2019
Publisher: Springer Berlin Heidelberg
Published in: European Journal of Pediatrics / Issue 3/2019
Print ISSN: 0340-6199
Electronic ISSN: 1432-1076
DOI: https://doi.org/10.1007/s00431-018-3295-7

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Refeeding in anorexia nervosa

Abstract

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

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