Striking a balance between
refeeding and underfeeding.
Reprinted from Eating Disorders Review
November/December 2012 Volume 23, Number 6
©2012 Gürze Books
Even in cases of extreme malnutrition, enteral (EN) feeding may be a well-tolerated method of refeeding patients with anorexia nervosa (AN), according to Dr. Maria Gabriela Gentile, of the Eating Disorders Unit at Niguarda Hospital, Milan, Italy (Nutrients 2012; 4, 1293; doi: 10.3390/nu4091293).
According to Dr. Gentile, refeeding severely malnourished patients presents two very complex and sometimes conflicting tasks: (1) to avoid the “refeeding syndrome” caused by overly rapid correction of malnutrition, and (2) to avoid “underfeeding” caused by taking a too-cautious approach to refeeding.
Severely malnourished patients have poor myocardial contractility and their circulatory volume should be carefully evaluated. Electrolyte disturbances are also common, along with vitamin deficiencies. Nutritional support for such patients aims to restore lean body mass, to preserve or to restore immune function, to avert metabolic complications, to attenuate oxidative cellular injury and metabolic response to stress of starvation, and finally to prevent heart and respiratory failure. For patients with extreme malnutrition and life-threatening weight loss or those unable or unwilling to eat an adequate oral diet, artificial nutrition is indicated.
A study of 10 severely undernourished AN patients
Dr. Gentile and colleagues described the course of refeeding 10 patients with AN who averaged 22 years of age, and who presented with a mean initial body mass index of 11.2 kg/m2. For those patients with life-threatening illness, immediate nutritional support with EN was initiated at a low rate with temporary nasogastric feeding; this was closely monitored and regulated via an electronically operated pump. Nasogastric feeding was the preferred procedure because it is a safe and simple, nonsurgical procedure, according to the authors. For patients not affected by any specific disease (for example, those with renal or hepatic insufficiency or diabetes), it was possible to use a polymeric diet free of lactose and gluten, in the form of a high-nitrogen, complete fluid formula. To lessen gastric discomfort and avoid fluid overload, the researchers used a high-calorie formula (1.7-2.0 kcal/mL) for most patients. A team of dietitians helped patients choose their own meals and provided a personalized diet plan.
To avoid hypoglycemic episodes, the researchers used a combination of continuous EN and intravenous fluid 10% glucose over 24 hours. The clinicians started oral phosphate supplements and/or sodium phosphate even before a complete serum electrolyte panel was available. The phosphate dose was evaluated in each patient because the amounts were highly variable and required strict daily monitoring of serum phosphate levels. The range of phosphate supplementation ranged from 80 to 1000 mg/day. Potassium and magnesium ere added according to serum levels. Patients’ body weights were checked at least once a day.
Results
Patients’ mean BMI increased from 11.2 kg/m2 to 17.3 kg/m2, and none developed refeeding syndrome. Dr. Gentile noted that there was only one episode of severe hypoglycemia (glucose: 38 mg/dL) on the 90th day or treatment, when the patient was being treated only with an oral diet. Three patients had hypophosphatemia (phosphate level <3 mg/dL) before starting treatment, but never again during the 90 days of treatment. The approach included continuous monitoring of fluid intake, to avoid fluid overload with refeeding edema and cardiac failure. Patients were weighed at least once a day, tissues were checked for edema daily, and water intake by mouth was monitored. Dr. Gentile noted that metabolic complications were prevented by careful monitoring, particularly to prevent hypoglycemia, which is always a possibility because the liver lacks enough substrate to maintain the patient’s glycemia.
The researchers feel that the combined use of continuous EN and intravenous IV fluid with 10% glucose over 24 hours prevented hypoglycemia episodes. The 24-hour continuous supplementation by EN was selected to reduce gastric discomfort, diarrhea, and metabolic alterations. Only when the degree of malnutrition was partially corrected did they gradually reduce the infusion time.
