264 Koletzko^Refeeding Syndrome and Outcome
The risk of refeeding syndrome is highest in AN
patients with severe underweight, which is a better
risk predictor than total energy intake [8]. The first
week after starting enteral nutrition is the time with
the highest rate of refeeding syndrome manifesta-
tions. To reduce the risk, a patient’s nutritional sta-
tus and hydration as well as serum electrolytes,
magnesium and phosphate should be assessed pri-
or to initiating tube feeding. During the initial
phase of refeeding, daily monitoring of plasma
electrolytes, phosphate, magnesium, calcium, urea
and creatinine as well as of cardiac status (pulse,
heart failure) is advisable [8]. Initial enteral feeding
should be limited to provide only about three quar-
ters of the estimated requirements in severe cases
(i.e. 11–14 years: 45 kcal/kg per day; 15–18 years:
40 kcal/kg per day). If this supply is tolerated and
no imbalances are encountered, the supply may be
gradually increased over 1–3 weeks towards reach-
ing intakes that achieve a sustainable weight gain.
Frequent small feeds with an energy density of 1
kcal/ml should be used in order to minimize fluid
load. The following supplements may be provided:
Na + at 1 mmol/kg per day, K + at 4 mmol/kg per
day, Mg 2+ at 0.6 mmol/kg per day and phosphate
at ≤ 100 mmol orally for children and adolescents
5 years of age [8]. An occurring hypocalcaemia
must be corrected. Thiamine, riboflavin, folic acid,
ascorbic acid, pyridoxine and fat-soluble vitamins
should be supplemented along with trace elements.
Patients with a BMI <16, weight loss of >15% with-
in the previous 3–6 months, very little or no nutri-
ent intake for >10 days, and low levels of potassi-
um, phosphate or magnesium prior to any feeding
are considered a high-risk group for developing
refeeding syndrome and should not only have an
initial restriction of their protein and energy intake
but also be given thiamin and other B group vita-
mins, a balanced multivitamin and trace element
supplement, as well as potassium, magnesium and
phosphate under close monitoring of plasma con-
centrations.
Agostino et al. [9] reviewed the outcomes of
AN patients treated with nasogastric tube feed-
ing or a standard bolus meal treatment in one
centre. The patients with nasogastric tube feed-
ing had a significantly shorter hospital stay (33.8
vs. 50.9 days; p = 0.0002) and an improved rate of
weight gain, while the rate of complications or
electrolyte abnormalities with prophylactic phos-
phate supplementation from admission was not
different. One may conclude that even though an
individualized approach to refeeding AN pa-
tients is appropriate, the available data support
the option of treating undernourished AN inpa-
tients with nasogastric tube feeding while using
appropriate precautions and monitoring.Conclusions- AN patients require inpatient or outpatient
psychiatric treatment, but they also regularly
need treatment involving experts in nutrition-
al rehabilitation - Nutritional rehabilitation aims at only a mod-
erate rate of weight gain up to ∼ 1 kg/week - Refeeding can be achieved by increased nutri-
ent intake from foods, oral nutritional supple-
ments or tube feedings but is often made dif-
ficult by the denial of illness and resistance to
treatment frequently found in AN patients - A slow initiation of refeeding as well as close
monitoring are needed, particularly in mark-
edly malnourished patients, to reduce the risk
of refeeding syndrome and hypophosphatae-
mia - The energy intake in AN patients needs to be
slowly increased to ∼ 60–100 kcal/kg per day to
achieve a sustained weight gain, partly due to
high energy expenditure resulting from exces-
sive physical activity - In addition to regular foods, the use of oral nu-
tritional supplements and nasogastric tube
feedings is a suitable option for refeeding AN
patients
Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 259–265
DOI: 10.1159/000375192