Article

Does Aggressive Refeeding in Hospitalized Adolescents With Anorexia Nervosa Result in Increased Hypophosphatemia?

Department of Nutrition and Food Services, Royal Children's Hospital, Victoria, Australia.
Journal of Adolescent Health (Impact Factor: 3.61). 06/2010; 46(6):577-82. DOI: 10.1016/j.jadohealth.2009.11.207
Source: PubMed
ABSTRACT
Concerns about refeeding syndrome have led to relatively conservative nutritional rehabilitation in malnourished inpatients with anorexia nervosa (AN), which delays weight gain. Compared to other programs, we aggressively refed hospitalized adolescents. We sought to determine the incidence of hypophosphatemia (HP) in 12-18-year-old inpatients in order to inform nutritional guidelines in this group.
A 1-year retrospective chart review was undertaken of 46 admissions (29 adolescents) with AN admitted to the adolescent ward of a tertiary children's hospital. Data collected over the initial 2 weeks included number of past admissions, nutritional intake, weight, height, body mass index, and weight change at 2 weeks. Serum phosphorus levels and oral phosphate supplementation was recorded.
The mean (SD) age was 15.7 years (1.4). The mean (SD) ideal body weight was 72.9% (9.1). Sixty-one percent of admissions were commenced on 1,900 kcal (8,000 kJ), and 28% on 2,200 kcal (9,300 kJ). Four patients were deemed at high risk of refeeding syndrome; of these patients, three were commenced on rehydration therapy and one on 1,400 kcal (6,000 kJ). All patients were graded up to 2,700 kcal (11,400 kJ) with further increments of 300 kcal (1,260 kJ) as required. Thirty-seven percent developed mild HP; no patient developed moderate or severe HP. Percent ideal body weight at admission was significantly associated with the subsequent development of HP (p = .007).
These data support more aggressive approaches to nutritional rehabilitation for hospitalized adolescents with AN compared to current recommendations and practice.

Full-text

Available from: Susan Sawyer
Original article
Does Aggressive Refeeding in Hospitalized Adolescents With
Anorexia Nervosa Result in Increased Hypophosphatemia?
Melissa Whitelaw, B.App.Sc. (Phys.Ed.), B.App.Sc. (Hlth.Sc.), B.Nutr.Diet., A.P.D.
a,b,
*
,
Heather Gilbertson, Adv.A.P.D., Ph.D.
a
, Pei-Yoong Lam, M.B.B.S.
b
,
and Susan M. Sawyer, M.D.
b,c
a
Department of Nutrition and Food Services, Royal Children’s Hospital, Victoria, Australia
b
Centre for Adolescent Health, Royal Children’s Hospital, Melbourne, Australia
c
Department of Pediatrics, The University of Melbourne and Murdoch Children’s Research Institute, Victoria, Australia
Manuscript received June 11, 2009; manuscript accepted November 18, 2009
Abstract Purpose: Concerns about refeeding syndrome have led to relatively conservative nutritional rehabil-
itation in malnourished inpatients with anorexia nervosa (AN), which delays weight gain. Compared to
other programs, we aggressively refed hospitalized adolescents. We sought to determine the incidence
of hypophosphatemia (HP) in 12–18-year-old inpatients in order to inform nutritional guidelines in
this group.
Methods: A 1-year retrospective chart review was undertaken of 46 admissions (29 adolescents) with
AN admitted to the adolescent ward of a tertiary children’s hospital. Data collected over the initial 2
weeks included number of past admissions, nutritional intake, weight, height, body mass index, and
weight change at 2 weeks. Serum phosphorus levels and oral phosphate supplementation was
recorded.
Results: The mean (SD) age was 15.7 years (1.4). The mean (SD) ideal body weight was 72.9%
(9.1). Sixty-one percent of admissions were commenced on 1,900 kcal (8,000 kJ), and 28% on
2,200 kcal (9,300 kJ). Four patients were deemed at high risk of refeeding syndrome; of these patients,
three were commencedon rehydration therapy and one on 1,400 kcal (6,000 kJ). All patients were graded
up to 2,700 kcal (11,400 kJ) with further increments of 300 kcal (1,260 kJ) as required. Thirty-seven
percent developed mild HP; no patient developed moderate or severe HP. Percent ideal body weight
at admission was significantly associated with the subsequent development of HP (p ¼ .007).
Conclusions: These data support more aggressive approaches to nutritional rehabilitation for hospi-
talized adolescents with AN compared to current recommendations and practice. ! 2010 Society for
Adolescent Health and Medicine. All rights reserved.
Keywords: Anorexia nervosa; Refeeding; Hypophosphatemia; Refeeding syndrome; Nutrition; Adolescents
Weight restoration is essential for the immediate stabiliza-
tion of the acute cardiovascular complications of anorexia
nervosa (AN). In the medi um term, patients with AN who
are discharged with low weight are more likely to be readmit-
ted than those discharged at higher weight [1–3]. In the
longer term, weight restoration is critical in ameliorating
physical complications such as pubertal delay and stunting,
amenorrhea, impaired bone mineral acquisition, as well as
changes in the brain [2,4].
It is now well appreciated that refeeding syndrome (RS)
and sudden death are potential sequelae when severely
malnourished patients are aggressively refed [5]. RS was first
documented by Josephus Flavious in the first Century when
Jews, captured and starved by the Romans, later gorged
*Address correspondence to: Melissa Whitelaw, B.App.Sc.(Phys.Ed.),
B.App.Sc.(Hlth.Sc.), B.Nutr.Diet., A.P.D., Department of Nutrition and
Food Services, Royal Children’s Hospital, Flemington Road, Parkville,
Victoria, Australia 3052.
E-mail address: melissa.whitelaw@rch.org.au
1054-139X/$ see front matter ! 2010 Society for Adolescent Health and Medicine. All rights reserved.
doi:10.1016/j.jadohealth.2009.11.207
Journal of Adolescent Health 46 (2010) 577–582
Page 1
themselves and subsequently died [cited in 6]. In the 1940s,
Ancel Keys’ classic Minnesota Experiment provided scien-
tific evidence for the cardiopulmonary and neurologic risks
of oral refeeding after starvation [7]. RS is a complex condi-
tion that occurs as a result of severe electrolyte and fluid shifts
in response to refeeding. While hypophosphatemia (HP) is
considered the hallmark of RS, hypokalemia and hypomag-
nesia may also occur. Sequelae of HP can include cardiac,
neurologic, respiratory, renal, and hematologic complica-
tions [8–10].
Concerns of RS have resulted in the widespread use of
hypocaloric diets compared to current recommendations
and practice [11], which significantly compr omise weight
gain. More specifically, the lack of clinical e vidence around
RS has resulted in a lack of consensus about how best to
approach energy and nutrition prescription in patients with
AN. Given that the medical complications of AN can gener-
ally be reversed with timely nutritional restoration [2], nutri-
tion prescription needs to carefully balance the risk of RS
with the value of high-energy diets in achieving timely
weight restoration.
We set out to determine the incidence of HP in 12–18-
year-old inpatients in order to inform the development of
nutritional guidelines for hospitalized adolescents with AN.
This was with the knowledge that in comparison to many
eating disorder programs and dietary recommendations, we
prescribe aggressive energy replacement.
Since 2002, a total of 309 adolescent AN patients have
been refed using this refeeding protocol. More detailed anal-
ysis was conduct ed over a 12-month audit period to explore
the effects of this refeeding protocol. We hope that this report
will serve as a stimulus for further research and future clinical
practice guideline development around nutritional and
energy requirements in adolescents wi th AN .
Methods
Setting
Within a tertiary children’s hospital, we run a comprehen-
sive program on adolescent eating disorders. The focus is on
outpatient care, with the goal of avoiding hospitalization. The
most common reason for admission is failure of outpatient
care (weight loss and physiological instability despite inten-
sive interventions) or when the patient presents to the emer-
gency department so medically unwell that discharge to
outpatient follow-up is not appropriate.
Study design and sample
Ethical approval was obtained from the Hospital Ethics
and Research Committee. A 1-year retrospect ive chart
review (July 2007–June 2008) was conducted of 46 admis-
sions with AN who were consecutively admitted to the hospi-
tal’s adolescent ward. A total of 29 inpatients were reviewed.
Patients were included if they met Diagnostic and Statistical
Manual of Mental Disorders, Fourth edition (DSM-IV)
criteria for AN, binge-purge, or restrictive subtype [12].
Patients were excluded from the study if they had been trans-
ferred from another hospital, were younger than 12 years, or
diagnosed with Bulimia Nervosa or Eating Disorder Not
Otherwise Specified.
Retrospective data were collected for the first 2 weeks of
admission. This included the number of past admissions,
nutritional intake, weight, height, body mass index, The
Centers for Disease Control and Prevention body mass index
centiles [13], and weight change at 2 weeks. Serum phos-
phorus levels and details of oral phosphate supplementation
were also reviewed.
Nursing staff measured weight and height twice a week
before breakfast, with patients wearing gowns and having
voided. Centers for Disease Control and Prevention growth
charts were used for calculating weight and height centiles
[13]. Percentage ideal body weight (%IBW) was calculated
as a ratio of expected weight for height.
Mild HP was classified as serum phosphorus less than 3.4
mg/dL or 1.10 mmol/L as per our hospital pathology guide-
lines. Moderate HP was defined as 2.5–1.0 mg/dL (.80–.31
mmol/L) [10] and severe HP defined as <1.0 mg/dL (.31
mmol/L) [10,14,15]. These categories are based on the incre-
mental risk for the development of RS [10].
Anorexia nervosa inpatient refeeding protocol
On admission, the medical team reviewed serum bloods,
vital signs, wei ght history, and the degree of malnutrition.
The dietitian assessed recent food and fluid intake. Patients
were prescribed a minimum of 1,900 kcal (8,000 kJ) on
Day 1, grading up to 2,200 kcal (9,300 kJ) on day 3 and
2,700 kcal (11,400 kJ) on day 5. Further increments of 300
kcal (1,260 kJ) were made if weight gain was less than 500
g at each biweekly weighing. The exception to this was
when patients were deemed to be at significant risk of RS;
these were commenced on either rehydration therapy (oral
or enteral) or a modified meal plan that initially provided
1,400 kcal (6,000 kJ).
Nutrition was offered as regular food and drinks. High-
energy nutritional supplementary drinks were used only
when meal plans needed to be increased above 2,700 kcal
(11,400 kJ). Neither glucose polymers nor fats were added
to increase the normal caloric density of foods. Patients
unable to complete meals and snacks received bolus feeds
through a nasogastric tube to supplement oral intake.
All meals were supervised by nursing staff who sat with
patients for the duration of each meal and snack. All pati ents
had supervised bed rest for 1 hour post meals and half an hour
post snacks, during which time bathroom visits were not
allowed.
Meal plans were high in fat, providing 30%–40% of total
daily energy. Protein was prescribed above the recommended
dietary intake of 35–65 g protein per day [16]. Dairy foods
provided a minimum of 1,400 mg calcium per day, consti-
tuting 93% of the daily recommendation of 1,500 mg in
M. Whitelaw et al. / Journal of Adolescent Health 46 (2010) 577–582578
Page 2
AN [17] and 1,150 mg phosphorus per day (recommended
dietary intake ¼1,250 mg/d) [16]. Meal plans were nutrition-
ally complete [16]. Nutritional supplements such as multivi-
tamins or calcium were not prescribed.
Prophylactic phosphate supplementation was not
routinely prescribed. Instead, serum phosphorus was
reviewed daily in week 1 and less frequently in subsequent
weeks. Oral phosphate was prophylactically prescribed if
a patient was deemed at significant risk of RS. In practice,
this was individually determined based on measures of clin-
ical severity (e.g., severity of admission %IBW, hemody-
namic compromise, electrolyte derangements, h ydration
status, recent dietary intake, degree of weight loss, and
time frame of weight loss).
Oral phosphate was prescribed if serum phosphate levels
decreased below 3.4 mg/dL (1.10 mmol/L). When requi red,
oral phosphate supplementation ranged from 500 to 2,000
mg/d. As this was an audit of our practice it was not possible
to determine whether severe HP would have developed had
phosphate not been prescribed.
Statistical analysis
Data are reported using means and standard deviations for
quantitative characteristics, median and ranges for skewed
data or numbers and percentages for categorical characteris-
tics. Phosphorus levels were categorized as outlined, in addi-
tion to reporting the median day of phosphorus nadir.
Repeated measures were recorded for some patients during
this retrospective audit. When calculating and comparing the
outcome variables to incidence of HP using logistic regression,
correlation between values from the same patient was allowed
for using the cluster sandwich estimate of variance. All anal-
yses were performed using Stata 10.1 software [18].
Prescribed meal plans were analyzed with Foodworks
Professional, Version 4, 1998–2005 [19].
Results
The mean (SD) age of the 46 admissions was 15.7 (1.4)
years, with a mean (SD) %IBW of 72.9 (9.1). Sixty-one
percent of admissions commenced on a daily intake of
1,900 kcal (8,000 kJ), 28% on 2,200 kcal (9,300 kJ), and
2% commenced on 3,600 kcal (15,200 kJ). Four patients
were clinically considered at higher risk of RS, of whom
three commenced on rehydration therapy and one on 1,400
kcal (6,000 kJ). All patients were graded up to 2,700 kcal
(11,400 kJ) with further increments of 300 kcal (1,260 kJ)
as required. Fifteen percent required supplementary nasogas-
tric feeding. A total of 92% of all admissions commenced
with a minimum 1,900 kcal (8,000 kJ)/d up to a maximum
of 3,600 kcal (15,200 kJ). Initial caloric prescription for all
patients is illustrated in Figure 1 and compared with the
recommendations of the American Psychiatric Association
(APA) [20]. The mean (SD) weight gain in the first 2 weeks
of admission was 2.6 (1.3) kg (range, –.7 to 5.2 kg).
Serum phosphorus was recorded in 45 admissions, of
whom 17 (38%) developed HP. No patient developed
moderate or severe HP. Statistical analysis of patient vari-
ables compared to the incidence of HP was undertaken as
shown in Table 1, with significant correlation with %IBW
and admission number. Figure 2 illustrates the significant
correlation between %IBW and incidence of HP (p ¼ .007).
Twenty (43%) admissions received phosphate supple-
mentation. Of these, 14 were supplemented to rectify HP,
while six were prophylactically supplemented. Three of these
six still developed mild HP. Data were reanalyzed, excluding
those prophylacticall y supplemented (n ¼ 6) and showed no
significant difference in results between those prophylacti-
cally supplemented and the nonprophylact ically supple-
mented group.
There was a significant associati on between a lower
number of admissions and the development of HP (p ¼
.002). This may reflect the body’s adaptation to the physio-
logical consequences of chronic AN and prolonged starva-
tion. Those with HP were generally prescr ibed lower initial
energy, based on the clinical assessment of high risk for
RS, however the difference was not significant. The median
day of phosphorus nadir for all admissions was day 4 (range,
0–14 days).
Discussion
This study provides evidence to support our relatively
aggressive approach to nutritional prescription in underno ur-
ished inpatient s with AN. The majority of patients were
commenced on 1,900 kcal per day (8,000 kJ/d), with only
one in 2.6 experiencing mild HP. In our study, malnourished
patients with %IBW <68 were at the greatest risk of devel-
oping HP; lower initial energy prescription is recommended
in this group.
This approach for adolescents is consistent with the
Society for Adolescent Medicine and the American Academy
of Pediatrics, both of which recommend minimizing the risk
of RS in severe ly malnourished adolescents by gradually
increasing the caloric intake while carefully monitoring
0
500
1000
1500
2000
2500
3000
3500
4000
30kcal/kg 40kcal/kg 1(2%) 28(61%) 13(28%) 1(2%)
*3 (6%) patients were admitted for rehydration therapy
)yadlack(eulaV ci rolaClai t inI
Number of admissions*APA, 2000
Figure 1. Caloric value prescribed for commencement of refeeding
compared to recommendations by the American Psychiatric Association,
2000.
M. Whitelaw et al. / Journal of Adolescent Health 46 (2010) 577–582 579
Page 3
patients. The challenge for clinicians is that no specific energy
prescription is recommended by either organization [21–23].
In contrast, Sylvester and Forman recommend
commencing adolescents on 1,250–1,750 kcal/d (5,250–
7,350 kJ/d) based on nutritional intake prior to hospitaliza-
tion. When weight is less than 70% average weight, they
suggest that caloric prescription should be decreased [2].
Other recommendations do not differentiate between
adolescents and adults. The American Dietetic Association
[17] supports the recommendation of the APA [12,20] to
commence refeeding at 30–40 kcal/kg/d (126–168 kJ/kg/d)
of actual weight, or 1,000–1,200 kcal/d (4,200–5,040 kJ/d)
as the starting point from which to gradually grade up feeds
for all ages. Similarly, the Royal Australian and New Zealand
College of Psychiatry guidelines advise introducing food
cautiously, recommending 600–800 kcal/d (2,520 –3,360
kJ/d) [24]. The mean weight in our cohort was 41.5 kg, which
equates to 1,250–1,670 k cal/d (5,200–7,000 kJ/d). As shown,
we commenced refeeding the majority of our inpatients at
significantly greater energy prescription than these recom-
mendations.
More widely, there is diversity of other recommendations
about energy prescription. Golden and Meyer suggest 1,000–
1,400 kcal/d (4,200 –5,880 kJ) grading up by 200–300 kcal
(840–1,260 kJ) every 24–48 hours [25]. Others recommend
20 kcal/kg (84 kJ/kg) or 1,000 kcal/d (4,200 kJ/d) [8,26],
while another recommendation is to commence at 25%–
50% of estimated requirements [27].
Perhaps not surprisingly, there is equally wide variation in
clinical practice. A recent review of North American physi-
cians identified that for a specific adolescent patient profile,
the initial energy prescription ranged by a factor of 15,
from a low of 100 kcal (420 kJ) to a high of 1,500 kcal
(6,300 kJ) [11]. In comparison, within our program, 93%
of admissions were commenced on a minimum 1,900 kcal
(8,000 kJ) without adverse outcomes.
No calculation accurately prescribes the caloric require-
ments in AN [8]. Resting energy expenditure has been
compared with indirect calorimetry and various predictive
equations; however, these equations (e.g., Fleisch, Harris
Benedict, FAO, Schofield-HW, Schedenbach) have gener-
ally overestimated the estimated energy requirements
compared to the gold standard of indirect calorimetry [28] .
Might patients be adversely affected psychologically by
the larger meals necessitated by these energy prescriptions?
We only use nasogastric tubes for refeeding patients who
are unable to complete prescr ibed meals. That 85% of admi s-
sions did not require enteral feeding suggests most patients
are able to manage this amount.
Our findings show that patients with a low %IBW (<68%)
were at great er risk of developing HP. This is consistent with
other reports where malnourished patients with less than or
equal to 70% average body weight or IBW were at increased
risk [2,5,9,20,29]. Our study supports recommendations to
refeed such patients more slowly [5,8] . However, that RS
has been described in a pa tient with 61% IBW who was
commenced on only 500 kcal/d [5] highlights the need for
rigorous monitoring [4,5,30].
Ornstein et al. reported that 27% of 69 adolescent patients
required phosphate supplementation in response to
Table 1
Correlation of variables compared with hypophosphatemia
Normophosphatemic Hypophosphatemic *p value
n ¼ 28 n ¼ 17
Age (years) 15.9 (SD) 1.4 15.4 (SD) 1.3 .25
Admission number (mean) 5.1 (SD) 4.8 2.4 (SD) 1.8 .002
Admission Wt (kg) 41.8 (SD) 7.3 40.9 (SD) 6.4 .65
Admission Ht (cm) 163.4 (SD) 8.2 164.6 (SD) 6.5 .64
Admission % ideal body weight for age and height 75.4 (SD) 6.9 68.4 (SD) 10.9 .007
BMI (kg/m
2
) 15.6 (SD) 1.5 15.1 (SD) 1.9 .38
BMI z score –2.2 (SD) 0.6 –2.3 (S.D) 0.8 .54
Mean Wt gain in 2/52 (kg) 2.5 (SD) 1.2 2.9 (SD) 1.2 .38
Mean energy prescribed (kcal) 1,950 (SD) 409 1,682 (SD) 654 .13
N (%) Rehydration on admission 1 (3.6%) 2 (11.8%) .33
N (%) NG feeds 3 (10.7%) 4 (23.5%) <.28
* Adjusted for repeated measures.
.8
1
1.2
1.4
1.6
50
60
70
90
%IBW
lowest
Fitted values
L/ lo mmsurohpsohP
Figure 2. Relationship between %IBW at admission and serum phosphorus
nadir for 45 admissions. The dotted line indicates the cut off for HP.
M. Whitelaw et al. / Journal of Adolescent Health 46 (2010) 577–582580
Page 4
phosphate <3.2 mg/dL (.99 mmol/L). This was despite re-
feeding at a conservative 1,200–1,400 kcal/d and that more
than 75% reached their phosphorus nadir in the first week
of being hospitalized [9]. While 37% of our admissions
required supplementation with more aggressive refeeding,
none had phosphate levels <2.6 mg/dL (.81 mmol/L) nor
any symptoms of RS. Fifty percent of our admissions reached
their phosphorus nadir at day 4, and consistent with Ornstein
et al. [9], 75% of admissions reached their nadir within the
first week. This supports the need for daily review of serum
phosphorus in week 1 and ongoing review in week 2.
Prophylactic phosphate supplementation remains conten-
tious [8,9,30]. Daily phosphate supplementation for all
patients is advocated by some [2,8,31], while others recom-
mend close monitoring and supplementation when indicated
[9,10]. Our findings suppor t monitoring of phospho rus with
supplementation as required, as almost two in three admis-
sions did not require supplementation. Within our study,
the wide variation in phosphate nadir for the same %IBW
is noteworthy.
Our study was a small, detailed audit of actual refeeding
practices using high-energy supplementation. The authors
are not aware of any published data reviewing the incidence
of HP in the context of refeeding adolescents at energy levels
equivalent to those documented in this audit. While a random-
ized controlled trial of high-energy refeeding versus current
recommendations would determine actual diff erences in HP
and RS, the low incidence of clinically significant refeeding
complications means that very large numbers would be
required. We believe that furt her reassurance can be gained
by the number of adolescents we have refed since 2002 using
this protocol, without clinical complications of refeeding.
Our calculations for energy intake were based on what
was prescribed without taking into account variation in
serving sizes or what was actually eaten. Compensatory
behaviors such as purging and laxative abuse were not taken
into account, nor was adherence with phosphate supplemen-
tation, surreptitious exercising or water loading. Possible
diurnal variation in serum phosphate was also not considered.
That those deemed clinically at greater risk of refeeding
commenced at a lower caloric prescription also limits the
interpretation of this study. However, all but four adolescents
in our program had a higher initial caloric prescr iption than
the APA recommendations.
Are adolescents with AN more or less at risk of RS than
adults? The various practice guidelines [17,20,32] include
three that are specifically for adolescents [2,21,22]. However,
there is no high-level evidence that compares the risks of re-
feeding adolescents versus adults. In comparison to adoles-
cents, the extent of chronicity in adults hospitalized with
AN could arguably place them at greater risk of RS due to
longstanding malnutrition. In contrast, higher metabolic rates
in adolescents could arguably place them at greater risk than
adults. Further research is required to address this question.
It has been suggested that, ‘A little nutrition support is
good, too much is lethal’ [8]. Although hospitalized patients
with AN should always be carefully monitored for RS, the
extent of malnutrition in previous eras and concerns of RS
may overly influence contemporary refeeding protocols.
Given the importance of weight gain in patients with AN,
we urge that as much consideration is given to safe
approaches to weight gain as to the risk of RS.
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M. Whitelaw et al. / Journal of Adolescent Health 46 (2010) 577–582582
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    • "The current study reported a smaller percentage of complications of refeeding, despite starting patients on a mean caloric intake of 2611.7 kcal/day, equivalent to 58 kcal/kg/day. In addition to reporting the highest starting caloric intake compared with other studies [8, 11,[17][18][19][20][21][22][23], we also report a greater average rate of weight gain of 2.1 kg/week which is almost double that recommended in most guidelines [1, 3, 7, 10] and just above the upper range in more recent guidelines [9]. These findings suggest that, with adequate patient monitoring and appropriate supplementation, rapid weight restoration can be safely achieved without developing RFS. "
    [Show abstract] [Hide abstract] ABSTRACT: . This study examines weight gain and assesses complications associated with refeeding hospitalised adolescents with restrictive eating disorders (EDs) prescribed initial calories above current recommendations. Methods . Patients admitted to an adolescent ED structured “rapid refeeding” program for >48 hours and receiving ≥2400 kcal/day were included in a 3-year retrospective chart review. Results . The mean (SD) age of the 162 adolescents was 16.7 years (0.9), admission % median BMI was 80.1% (10.2), and discharge % median BMI was 93.1% (7.0). The mean (SD) starting caloric intake was 2611.7 kcal/day (261.5) equating to 58.4 kcal/kg (10.2). Most patients (92.6%) were treated with nasogastric tube feeding. The mean (SD) length of stay was 3.6 weeks (1.9), and average weekly weight gain was 2.1 kg (0.8). No patients developed cardiac signs of RFS or delirium; complications included 4% peripheral oedema, 1% hypophosphatemia (
    Full-text · Article · Jan 2016 · Journal of nutrition and metabolism
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    • "The early weight gain in this study contrasts with treatment centres following currently published guidelines who universally report a decrease in weight during the first week of refeeding [21] . In the case of malnourished AN patients presenting with medical instability, the provision of insufficient calories to meet resting energy expenditure has been shown to prolong medical instability and the length of hospitalisation in this patient group [15,2122232425 . There was no significant difference in weight gain between treatment sites when weight was related to gender, age and height, suggesting the replicability of this protocol. "
    [Show abstract] [Hide abstract] ABSTRACT: 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. 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. 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. 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. Australian Clinical Trials Register number: ACTRN012607000009415.
    Full-text · Article · Dec 2015 · Journal of Eating Disorders
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    • "Refeeding hypophosphatemia is correlated with the degree of malnutrition on admission rather than the initial calories prescribed in BMI ¼ body mass index. One or more of the above mentioned classification would suggest mild, moderate , or severe malnutrition.Table 2 Indications supporting hospitalization in an adolescent with an eating disorder One or more of the following justify hospitalization: 1. 75% median body mass index for age and sex 2. Dehydration 3. Electrolyte disturbance (hypokalemia, hyponatremia, and hypophosphatemia) 4. EKG abnormalities (e.g., prolonged QTc or severe bradycardia) 5. Physiological instability Severe bradycardia (heart rate <50 beats/minute at daytime; <45 beats/minute at night) Hypotension (<90/45 mm Hg) Hypothermia (body temperature <96 F, 35.6 C) Orthostatic increase in pulse (>20 beats per minute) or decrease in hospitalized adolescents with AN [55,57,61,63]. The optimal starting caloric prescription or rate of advancement of calories to maximize nutritional rehabilitation without increasing risks for the refeeding syndrome is not known, especially in the most severely malnourished patients. "
    [Show abstract] [Hide abstract] ABSTRACT: The medical practitioner has an important role to play in the management of adolescents with eating disorders, usually as part of a multidisciplinary team. This article reviews the role of the medical practitioner in the diagnosis and treatment of eating disorders, updating the reader on the changing epidemiology of eating disorders, revised diagnostic criteria, newer methods of assessing degree of malnutrition, more aggressive approaches to refeeding, and current approaches to managing low bone mass. Copyright © 2015 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.
    Full-text · Article · Feb 2015 · Journal of Adolescent Health
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