Management and Prevention of Refeeding …...4/18/20 1 Management and Prevention of Refeeding Syndrome in Patients with Restrictive Eating Disorders Kendel Rose-Chojnacki 1 Objectives

4/18/20

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Management and Prevention of Refeeding Syndrome in Patients with Restrictive Eating Disorders

Kendel Rose-Chojnacki

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Objectives

Provide an overview of refeeding

syndrome, what is known and unknown

1Bring awareness to patients at risk and current guidelines

2Challenge universal

best practice &

Evaluate safety of higher calorie feeding

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Personal Interest

• Experience working at a mental health facility

• Prolonged malnourishment • Hunger strike• Mental health diagnoses• religious preoccupation• hallucinations

• Alcohol and substance-use disorders• Eating disorders

• No standard protocol – further need to develop knowledge

Da Silva, J., Seres, D., Sabino, K., Adams, S., Berdahl, G., Citty, S., . . . Ayers, P. (2020). ASPEN Consensus Recommendations for Refeeding Syndrome. Nutrition in Clinical Practice, 35(2), 178-195.

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1OVERVIEW

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Introduction

• Refeeding Syndrome (RFS) is a rare, potentially deadly phenomenon• Often associated with critically ill patients started on tube feeding• Practices and protocols in place to prevent it • “Start low, go slow”

• New research - different ways to manage RFS for different cases?• ”Low and slow” may not be universal best practice

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Defining Refeeding Syndrome

ASPEN 2020 proposed consensus definition:

• Decrease in serum P, K and/or Mgand/or

• Resulting organ dysfunctionand/or

• Severe thiamine deficiency• Within 5 days of reintroducing calories


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PATHOLOGY OF REFEEDING SYNDROME

Stanga, Z., Brunner, A., Leuenberger, M., Grimble, R. F., Shenkin, A., Allison, S. P., & Lobo, D. N. (2008). Retrieved from https://www.researchgate.net/figure/Pathogenesis-and-features-of-the-refeeding-syndrome_fig1_6138422

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Signs and Symptoms of RFS

• Hypophosphatemia• Hypomagnesemia• Hypokalemia• Hypoglycemia• Thiamin Deficiency• Edema

• Respiratory failure• Cardiac arrhythmias• Cardiac arrest• Seizures• Coma• Excess infections• Death

Crook, M ., Hally, V., & Panteli, J. (2001). The im portance of the refeeding syndrom e. Nutrition , 17(7-8), 632-637.

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2RISK FACTORS & GUIDELINES

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Risk Factors for RFS

One or more:

• BMI < 16 kg/m2

• Weight loss > 15% in 3-6 months• Little to no intake > 10 days• Low K, Mg, P before feeding

Two or more:

• BMI < 18.5 kg/m2

• Weight loss > 10% in 3-6 months• Little to no intake > 5 days• Hx of alcohol abuse or drugs

• Includes chemo, insulin, antacids, or diuretics

Pilling S. NICE guidelines. Ann Gen Psychiatry. 2010;9(Suppl 1):S53. Published 2010 Apr 22. doi:10.1186/1744-859X-9-S1-S53

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Populations at Risk

Bariatric Surgery and bowel resection

Malabsorption

Child abuse and starvation

Military recruits

Athletes

Renal failure/HD

Critically Ill

Starvation in protest

Cancer

Mental health disorders

Alcohol and substance-abuse

Anorexia nervosa Da Silva, J., Seres, D., Sabino, K., Adams, S., Berdahl, G., Citty, S., . . . Ayers, P. (2020). ASPEN Consensus Recommendations for Refeeding Syndrome. Nutrition in Clinical Practice, 35(2), 178-195.

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General Management of Refeeding for High Risk Individuals

Historical standard: “start

low, go slow”

Start at 5 kcal/kg/d

(severe) up to 20-25 kcal/kg/d

Slowly introduce calories 4-10 days

until goal met

Closely monitor electrolytes

(first 72 hours)

Thiamine supplementation


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3IS HIGHER CALORIE REFEEDING SAFE IN

CERTAIN POPULATIONS?

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Outcomes of an Inpatient Refeeding Protocol in Youth with Anorexia Nervosa: Rady Children’s

Hospital San Diego/University of California, San Diego

Study 1

Maginot, Tamara R., Kumar, Maya M., Shiels, Jacqueline, Kaye, Walter, & Rhee, Kyung E. (2017). Outcomes of an inpatient refeeding protocol in youth with anorexia nervosa:

Rady Children's Hospital San Diego/University of California, San Diego. Journal of Eating Disorders, 5(1), 1.

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Overview

PurposeTo evaluate the safety of a higher calorie refeeding protocol in adolescent patients with restrictive eating disorders

Design Observational Study – Retrospective Chart Review

Intervention Oral nutrition rehabilitation protocol using high or low starting calorie prescription

Primary Outcomes Electrolyte abnormalities and length of stay

Maginot, Tamara R., Kumar, Maya M., Shiels, Jacqueline, Kaye, Walter, & Rhee, Kyung E. (2017). Outcomes of an inpatient refeeding protocol in youth with anorexia nervosa: Rady Children's Hospital San Diego/University of California, San Diego. Journal of Eating Disorders, 5(1), 1.

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Participants

Inclusion Criteria• 8-20 years old• Dx AN, ARFID, or EDNOS• Met criteria for hospitalization• First or second hospital

admission

Exclusion Criteria• Dx Bulimia Nervosa• Left against medical advice• Transfer to different medical or

psychiatric facility• Admission to this hospital in last

30 days


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Methods

• Prescribed calorie level up to discretion of provider• Low calorie group = < 1500 kcal/d • Mean = 1185 kcal/d

• High calorie group = > 1500 kcal/d • Mean = 1781 kcal/d

• Aim for weight gain of 150-300 g/d• Calories increased in increments of 300 kcal/d

• Primarily oral feeding• Electrolytes & refeeding labs monitored daily


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Results

Low Calorie Group (n=21)

High Calorie Group (n=66)

P Value**

Hypophosphatemia* 57.1% 51.5% 0.65

Hypomagnesemia* 52.4% 51.5% 0.94

Hypokalemia* 19.1% 4.6% 0.03

Length of Stay 20.7 days 13.5 days <0.01

**P < 0.05 statistically significant

*frequency of development of in the first 72h of admission


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Results – Severely Malnourished Patients

Low Calorie Group High Calorie Group P Value **

Hypophosphatemia* 69% 60% 0.65

Hypomagnesemia* 6% 10% 0.72

Hypokalemia* 63% 50% 0.53

**P < 0.05 statistically significant

*frequency of development of in the first 72h of admission

• < 75% Expected Body Weight• n = 26


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Conclusions

Higher calorie refeeding may be supported in AN

Calories or rate not associated with electrolyte abnormalities

Degree of body depletion possibly better predictor of electrolyte abnormalities


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Overall EAL Rating: Negative

Strengths• Close monitoring of labs & vitals • Inclusion of severely

malnourished patients

Weaknesses• Observational study• Relatively small sample size• Calorie prescription based on

physician judgment• Rate of weight loss prior to

admission self reported


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Higher Caloric Intake in Hospitalized Adolescents with Anorexia Nervosa is Associated with

Reduced Length of Stay and No Increased Rate of Refeeding Syndrome

Study 2

Golden, N. H., Keane-Miller, C., Sainani, K. L., & Kapphahn, C. J. (2013). Higher Caloric Intake in Hospitalized Adolescents With Anorexia Nervosa Is Associated With Reduced

Length of Stay and No Increased Rate of Refeeding Syndrome. Journal of Adolescent Health, 53(5), 573–578. doi: https://doi.org/10.1016/j.jadohealth.2013.05.014

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Overview

Purpose: Determine the impact of higher calorie intake on weight gain, length of stay, and markers of refeeding syndrome in AN patients

Design: Observational Study – Retrospective Chart Review

Intervention: Oral nutrition rehabilitation protocol using high or low starting calorie prescription

Primary Outcomes: Electrolyte abnormalities and length of stay

Golden, N. H., Keane-Miller, C., Sainani, K. L., & Kapphahn, C. J. (2013). Higher Caloric Intake in Hospitalized Adolescents With Anorexia Nervosa Is Associated With Reduced Length of Stay and No Increased Rate of Refeeding Syndrome. Journal of Adolescent Health, 53(5), 573–578. doi: https://doi.org/10.1016/j.jadohealth.2013.05.014

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Participants

Inclusion Criteria

• 10– 21 years old• Dx AN• Mod/severe protein-calorie

malnutrition• Unstable vital signs• OR electrolyte disturbances

Exclusion Criteria

• Dx bulimia nervosa or EDNOS• Transferred after start of

nutrition intervention• Left AMA• Required NG feeding


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Methods

• High calorie group vs. low calorie group• High = ≥ 1400 kcal/d• Low = < 1400 kcal/d

• Oral refeeding + high calorie oral supplement• NG if needed

• Increased ~200 kcal every 24-48 hours

• Weight gain goal 0.2-0.5 kg/d

• Serum chemistries monitored every 24-48 hours• Supplemental P, Mg, & K if needed


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Results

P < 0.0001 statistically significant


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Conclusion

Refeeding at > 1,550 kcal/d leads to reduced LOS

High cal refeeding not associated with signs of RFS

Degree of malnutrition better predictor of RFS


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Overall EAL Rating: Neutral

Strengths• Large sample size• Severely malnourished patients

(n=49)• Specialized unit• Calorie intake and BMI assessed

prior to admission

Weaknesses• Retrospective study• Calorie level not randomized• Prophylactic P supplementation


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A Higher-Calorie Refeeding Protocol Does Not Increase Adverse Outcomes in Adult Patients

with Eating DisordersStudy 3

Matthews, K., Hill, J., Jeffrey, S., Patterson, S., Davis, A., Ward, W., . . . Capra, S. (2018). A Higher-Calorie Refeeding Protocol Does Not Increase Adverse

Outcomes in Adult Patients with Eating Disorders. Journal of the Academy of Nutrition and Dietetics, 118(8), 1450-1463.

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Overview

Purpose Compare incidence of RFS between low-cal and higher-cal protocol in adults with EDs

Design Retrospective pre-test-post-test

Intervention Oral & NG refeeding protocol using different prescribed kcal levels

Primary Outcomes Prevalence of electrolyte disturbance, hypoglycemia, edema and RFS dx

M atthews, K., Hill, J., Jeffrey, S., Patterson, S., Davis, A., Ward, W., . . . Capra, S. (2018). A Higher-Calorie Refeeding Protocol Does Not Increase Adverse Outcom es in Adult Patients w ith Eating Disorders. Journal of the Academy of Nutrition and Dietetics, 118(8), 1450-1463.

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Participants

Inclusion Criteria

• ≥ 18 years• ED diagnosis• Admitted to specialized unit

Exclusion Criteria

• Admitted from psychiatric unit• Admitted to ICU during

admission• Renal conditions• Pregnancy • < 5-day admission


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Methods

• Low-calorie control group (n=26)• December 2010 – August 2013• 875-1,000 kcal/d first 4-7 days• Primarily oral feeding• Advanced 500 kcal/d every 3-4 days• Goal 3,000 kcal

• Vitals, electrolytes, P, Mg, LFT daily until goal


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Methods Continued

• High-calorie group (n=93)• September 2013– January 2017• 1,500 kcal/d• NG tube within 24 hours• Fluid restricted to 250 ml/d• Advanced 500 kcal/d every 48 hours• Goal 3,000 kcal • Transition to oral after 48 hours at goal

• Vitals, electrolytes, P, Mg, LFT daily until goal


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Results

P < 0.05 statistically significant

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Conclusion

Higher calorie refeeding protocol may be safe in adults with EDs

Fewer hypoglycemic events occurred with higher refeeding protocol

Level of starting calorie prescription did not influence incidence of electrolyte disturbances or RFS diagnosis


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Overall EAL Rating: Neutral

Strengths• Relatively large sample size• Detailed protocol in isolated

time frames• Several clinical outcomes

measured & analyzed• Corrected for differences in BMI

Weaknesses• Retrospective study • Calorie groups not randomly

assigned• Differences in admission criteria• Difference in sample sizes


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The Role of the RD

•Recognize types of patients who may be at risk for RFS•Consider all factors when initiating a refeeding protocol • Individualize approaches to refeeding •Remain up to date with current research

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Future Directions

Research in all areas, age groups

& populations

RCTs, Reviews, Meta-Analyses

RFS definition, criteria and treatment

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Thank you

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References• Da Silva, J., Seres, D., Sabino, K., Adams, S., Berdahl, G., Citty, S., . . . Ayers, P. (2020). ASPEN Consensus

Recommendations for Refeeding Syndrome. Nutrition in Clinical Practice, 35(2), 178-195.• Stanga, Z., Brunner, A., Leuenberger, M., Grimble, R. F., Shenkin, A., Allison, S. P., & Lobo, D. N. (2008). Retrieved

from https://www.researchgate.net/figure/Pathogenesis-and-features-of-the-refeeding-syndrome_fig1_6138422• Crook, M., Hally, V., & Panteli, J. (2001). The importance of the refeeding syndrome. Nutrition, 17(7-8), 632-637.• Pilling S. NICE guidelines. Ann Gen Psychiatry. 2010;9(Suppl 1):S53. Published 2010 Apr 22. doi:10.1186/1744-859X-

9-S1-S53• Maginot, Tamara R., Kumar, Maya M., Shiels, Jacqueline, Kaye, Walter, & Rhee, Kyung E. (2017).

Outcomes of an inpatient refeeding protocol in youth with anorexia nervosa: Rady Children's Hospital San Diego/University of California, San Diego. Journal of Eating Disorders, 5(1), 1.

• Golden, N. H., Keane-Miller, C., Sainani, K. L., & Kapphahn, C. J. (2013). Higher Caloric Intake in Hospitalized Adolescents With Anorexia Nervosa Is Associated With Reduced Length of Stay and No Increased Rate of Refeeding Syndrome. Journal of Adolescent Health, 53(5), 573–578. doi: https://doi.org/10.1016/j.jadohealth.2013.05.014

• Matthews, K., Hill, J., Jeffrey, S., Patterson, S., Davis, A., Ward, W., . . . Capra, S. (2018). A Higher-Calorie Refeeding Protocol Does Not Increase Adverse Outcomes in Adult Patients with Eating Disorders. Journal of the Academy of Nutrition and Dietetics, 118(8), 1450-1463

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Documents

Management and Prevention of Refeeding …...4/18/20 1 Management and Prevention of Refeeding Syndrome in Patients with Restrictive Eating Disorders Kendel Rose-Chojnacki 1 Objectives