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 . 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. , 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
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’’ . 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.
 Baran SA, Weltzin TE, Kaye WH. Low discharge weight and outcome
in anorexia nervosa. Am J Psychiatry 1995;152:1070–2.
 Sylvester CJ, Forman SF. Clinical practice guidelines for treating
restrictive eating disorder patients during medical hospitalization.
Curr Opin Pediatr 2008;20:390–7.
 Steinhausen HC, Grigoroiu-Serbanescu M, Boyadjieva S, et al. Course
and predictors of rehospitalization in adolescent anorexia nervosa in
a multisite study. Int J Eat Disord 2008;41:29–36.
 Katzman DK. Medical complications in adolescents with anorexia
nervosa: A review of the literature. Int J Eat Disord 2005;37:S52–9.
 Kohn MR, Golden NH, Shenker IR. Cardiac arrest and delirium:
Presentations of the refeeding syndrome in severely malnourished
adolescents with anorexia nervosa. J Adolesc Health 1998;22:239–43.
 Barak N. Refeeding syndrome. Available at: http://bmj.bmjjournals.
com/cgi/eletters/328/7445/908. Accessed August 23, 2009.
 Keys A, Brozek J, Henschel A, et al. The Biology of Human Starvation.
In: Volumes, 1. Minneapolis, MN: University of Minnesota Press,
 Solomon SM, Kirby DF. The refeeding syndrome: A review. JPEN
 Ornstein RM, Golden NH, Jacobson MS, et al. Hypophosphatemia
during rehabilitation in anorexia nervosa: Implications for refeeding
and monitoring. J Adolesc Health 2003;32:83–8.
 Marinella MA. The refeeding syndrome and hypophosphatemia. Nutr
 Schwartz BI, Mansbach JM, Marion JG, et al. Variations in admission
practices for adolescents with anorexia nervosa: A North American
sample. J Adolesc Health 2008;43:425–31.
 American Psychiatric Association. Diagnostic and Statistical Manual
for Mental Health Disorders. 4th ed. Washington, DC: American
Psychiatric Association, 1994. 61–76.
 Centres for Disease Control and Prevention Available at http://www.cdc.
 Marik PE, Bedigan MK. Refeeding hypophosphatemia in critically ill
patients in an intensive care unit: A prospective study. Arch Surg
 Hayek ME, Eisenberg PG. Severe hypophosphatemia following institu-
tion of enteral feedings. Arch Surg 1989;124:1325–8.
 National Health and Medical Research Council. Nutrient reference
values for Australia and New Zealand. Executive summary. Canberra:
NHMRC Publications, Commonwealth of Australia, 2006.
 American Dietetic Association. Position of the American Dietetic
Association: Nutrition intervention in the treatment of anorexia nerv-
osa, bulimia nervosa, and other eating disorders. J Am Diet Assoc
 Stata Statistical Software [computer program]. Release 10.1. College
Station, TX: StataCorp, 2007.
 Xyris Software[computer program]. Australia Pty Ltd. Foodworks
Professional. Available at:http://www.xyris.com.au Accessed June,
 American Psychiatric Association. Practice guideline for the treatment
of patients with eating disorders (revision). Am J Psychiatry 2000;
M. Whitelaw et al. / Journal of Adolescent Health 46 (2010) 577–582 581