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Refeeding in anorexia nervosa

  • Clinical Algorithm
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Abstract

Refeeding in anorexia nervosa is a collaborative enterprise involving multidisciplinary care plans, but clinicians currently lack guidance, as treatment guidelines are based largely on clinical confidence rather than more robust evidence. It seems crucial to identify reproducible approaches to refeeding that simultaneously maximize weight recovery and minimize the associated risks, in addition to improving long-term weight and cognitive and behavioral recovery and reducing relapse rates. We discuss here various approaches to refeeding, including, among others, where, by which route, how rapidly patients are best refed, and ways of choosing between them, taking into account the precautions or the potential effects of medication or of psychological care, to define better care plans for use in clinical practice.

Conclusion: The importance of early weight gain for long-term recovery has been demonstrated by several studies in both outpatient and inpatient setting. Recent studies have also provided evidence to support a switch in current care practices for refeeding from a conservative approach to higher calorie refeeding. Finally, the risks of undernutrition/“underfeeding syndrome” and a maintenance of weight suppression are now better identified. Greater caution should still be applied for more severely malnourished < 70% average body weight and/or chronically ill, adult patients.

What is Known:

• Refeeding is a central part of the treatment in AN and should be a multidisciplinary and collaborative enterprise, together with nutritional rehabilitation and psychological support, but there are no clear guidelines on the management of refeeding in clinical practice.

• The risk of a refeeding syndrome is well known and well managed in severely malnourished patients (“conservative approaches”).

What is New:

• There is evidence that early weight restoration has an impact on outcome, justifying an aggressive approach to refeeding in the early stages of the illness.

• The risks of “underfeeding syndrome” and of a maintenance of weight suppression are now better identified and there is sufficient evidence to support a switch in current care practices for refeeding from a conservative approach to higher calorie refeeding.

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Abbreviations

AN:

Anorexia nervosa

BMI:

Body mass index

CDC:

Centers for Disease Control

FBT:

Family-based treatment

GH:

Growth hormone

IGF-1:

Insulin-like growth factor-1

MARSIPAN:

MAnagement of Really SIck Patients with Anorexia Nervosa

NG:

Nasogastric

PN:

Parenteral nutrition

RFS:

Refeeding syndrome

RH:

Refeeding hypophosphatemia

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Authors and Affiliations

  1. Assistance Publique-Hôpitaux de Paris, Service de Psychiatrie de l’Enfant et de l’Adolescent, Centre de Référence des Maladies Endocriniennes de la Croissance et du Développement, Hôpital Robert Debré, Paris, France

    Anne Bargiacchi & Julia Clarke

  2. Assistance Publique-Hôpitaux de Paris, Service d’Endocrinologie Diabétologie Pédiatrique, Centre de Référence des Maladies Endocriniennes de la Croissance et du Développement, Hôpital Robert Debré, Paris, France

    Anne Paulsen & Juliane Leger

  3. Université Paris Diderot, Sorbonne Paris Cité, Paris, France

    Juliane Leger

  4. Institut National de la Santé et de la Recherche Médicale (INSERM), Unité 1141, DHU PROTECT, Paris, France

    Juliane Leger

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  1. Anne Bargiacchi
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  2. Julia Clarke
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  3. Anne Paulsen
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  4. Juliane Leger
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Contributions

AB and JC did review the literature, AB wrote the first draft, and AP and JL made substantial corrections and corrected the first draft. All authors approved the final version of the manuscript.

Corresponding author

Correspondence to Anne Bargiacchi.

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The authors declare that they have no conflict of interest.

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This article does not contain any studies with human participants or animals performed by any of the authors.

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Communicated by Peter de Winter

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Bargiacchi, A., Clarke, J., Paulsen, A. et al. Refeeding in anorexia nervosa. Eur J Pediatr 178, 413–422 (2019). https://doi.org/10.1007/s00431-018-3295-7

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  • DOI: https://doi.org/10.1007/s00431-018-3295-7

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