Berthold Koletzko
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260 Koletzko Table 1. Guidelines of the American Psychiatric Association for nutritional rehabilitation in AN The goals of nutritional rehabilitation for seriously underweight patients are to restore weight, normalize eating patterns, achieve normal perceptions of hunger and satiety, and correct biological and psychological sequelae of malnutrition.
I
In working to achieve target weights, the treatment plan should also establish expected rates of controlled weight gain. Clinical consensus suggests that realistic targets are 2 – 3 lb/week for hospitalized patients and 0.5 – 1 lb/week for individuals in outpatient programs.
II
Registered dietitians can help patients choose their own meals and can provide a structured meal plan that ensures nutritional adequacy and that none of the major food groups are avoided.
I
It is important to encourage patients with AN to expand their food choices to minimize the severely restricted range of foods initially acceptable to them.
II Caloric intake levels should usually start at 30 – 40 kcal/kg per day (approx. 1,000 – 1,600 kcal/day). During the weight gain phase, intake may have to be advanced progressively to as high as 70 – 100 kcal/kg per day for some patients; many male patients require a very large number of calories to gain weight.
II
Patients who require much lower caloric intakes or are suspected of artificially increasing their weight by fluid loading should be weighed in the morning after they have voided and are wearing only a gown; their fluid intake should also be carefully monitored.
I
Urine specimens obtained at the time of a patient’s weigh-in may need to be assessed for specific gravity to help ascertain the extent to which the measured weight reflects excessive water intake.
I
Regular monitoring of serum potassium levels is recommended in patients who are persistent vomiters.
I Weight gain results in improvements in most of the physiological and psychological
complications of semistarvation.
I
It is important to warn patients about the following aspects of early recovery: I As they start to recover and feel their bodies getting larger, especially as they approach frightening, magical numbers on the scale that represent phobic weights, they may experience a resurgence of anxious and depressive symptoms, irritability and sometimes suicidal thoughts. These mood symptoms, non-food-related obsessional thoughts, and compulsive behaviours, although often not eradicated, usually decrease with sustained weight gain and weight maintenance. Initial refeeding may be associated with mild transient fluid retention, but patients who abruptly stop taking laxatives or diuretics may experience marked rebound fluid retention for several weeks. As weight gain progresses, many patients also develop acne and breast tenderness and become unhappy and demoralized about resulting changes in body shape. Patients may experience abdominal pain and bloating with meals from the delayed gastric emptying that accompanies malnutrition. These symptoms may respond to promotility agents.
III
When life-preserving nutrition must be provided to a patient who refuses to eat, nasogastric feeding is preferable to intravenous feeding.
I
I = Recommended with substantial clinical confidence; II = recommended with moderate clinical confidence; III = may be recommended on the basis of individual circumstances. Modified from American Psychiatric Association [3].
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
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moderate rate of weight gain up to ∼ 1 kg/week.
However, the implementation of increased nutri- ent intakes from foods, oral nutritional supple- ments or tube feedings is often made difficult by the denial of illness and resistance to treatment that is frequently found in AN patients, who tend to drop out of recommended treatment pro- grammes.
While healthy women without an eating dis- order require 20–40 kcal/kg per day to maintain their weight, the energy intake of AN patients needs to be increased stepwise to about 60–100 kcal/kg per day to achieve a sustained weight gain
[1] . This rather high energy need reflects a hyper- metabolic state, which in part may be due to ex- cessive physical activity and exercise – a common behaviour in AN. Increasing energy and nutrient intake to achieve nutritional rehabilitation can be approached either by increased intakes of regular foods, energy-dense oral nutritional supplements with an energy density of ≥ 1 kcal/ml, nasogastric tube feeding or a combination thereof. There is broad agreement that parenteral nutrition should generally be avoided unless a severely impaired gut function prevents the use of oral or enteral nutrition.
Table 2. Guidelines of the UK National Institute for Health and Clinical Excellence for nutritional rehabilitation in AN
Managing weight gain in AN
In most patients with AN, an average weekly weight gain of 0.5–1 kg in inpatient settings and 0.5 kg in outpatient settings should be an aim of treatment. This requires about 3,500–7,000 extra calories a week.
C
Regular physical monitoring, and in some cases treatment with a multivitamin/
multimineral supplement in oral form, is recommended for people with AN during both inpatient and outpatient weight restoration.
C
Total parenteral nutrition should not be used for people with AN, unless there is significant gastrointestinal dysfunction.
C Managing risk in AN
Health care professionals should monitor physical risks in patients with AN. If this leads to the identification of increased physical risks, the frequency and the monitoring and nature of the investigations should be adjusted accordingly.
C
People with AN and their carers should be informed if the risk to their physical health is high.
C The involvement of a physician or paediatrician with expertise in the treatment of
physically at-risk patients with AN should be considered for all individuals who are physically at risk.
C
Pregnant women with either current or remitted AN may need more intensive prenatal care to ensure adequate prenatal nutrition and fetal development.
C
Oestrogen administration should not be used to treat bone density problems in children and adolescents as this may lead to premature fusion of the epiphyses.
C
Evidence C: this grading indicates that directly applicable clinical studies of good quality are absent or not readily available. Modified from National Institute for Health and Clinical Excellence [4].
262 Koletzko
Benefits Disadvantages
Only regular foods
– It teaches skills for eating, promotes normal behaviour and challenges unhelpful coping strategies
– Less energy is delivered from food when compared with nasogastric feeding
– Patients experience the amount of food necessary for weight gain and weight maintenance
– Food makes hospital meal management home-like and realistic, which exposes patients to a situation which is anxiety-provoking, and gives them confidence in managing meals at home High-energy oral nutritional supplements –
–
Supplements can meet the high-energy
requirements needed for weight gain in a smaller volume than food
They are helpful as a top-up for patients struggling with satiety and the quantities of food required to promote weight gain
– The frequent use of supplements encourages patients away from the experience of food, re-enforces their avoidance of food and can foster dependency on artificial food sources
– It can be seen as a type of medicine Nasogastric tube feeding
–
–
–
More comfortable for the patient with less pain, physical discomfort and abdominal distension than large amounts of food
A helpful strategy aiding recovery:
it transfers the responsibility of weight gain from the patient to the treatment team;
if placed upon admission, it ‘medicalises’ the treatment and reduces the ‘power struggle’
between the patient and clinicians Opinions from patients and carers:
nasogastric feeding was seen as necessary by some patients because they believed they lacked the physical or psychological capacity to eat;
parents recognized it as a last resort that was required to keep their child alive;
it reduces the pressure patients perceive is being placed on them to eat and temporarily relieves them from the responsibility for adopting improved eating behaviours
– –
– –
– – –
It interferes with the fragile alliance between the patient and treatment team
The patient may feel disempowered and embittered towards the treatment team, which may have an impact on future personal and professional relationships
There is an emotional toll on staff treating involuntary patients
Not helpful for long term recovery:
patients may demonstrate an inability to maintain an adequate intake and weight gain once the tube is removed;
force-feeding in low-weight patients achieves little in relation to remitting illness or suffering;
patients tamper with the tube by adjusting the control, decanting the feed into other containers when unobserved, biting, and removing the tube
Medical complications (i.e. aspiration, nasal bleeding and nasal irritation, reflux and sinusitis)
The tube may not be inserted properly, which is more likely when patients have it inserted against their will Opinions from patients and carers:
it disguises the consumption of food;
patients become emotionally attached to and physically reliant on nasogastric feeding, and are anxious about the tube being removed;
it is used as a form of punishment and seen as a strategy that doctors use to assert their control Table 3. Benefits and disadvantages of different feeding methods in 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
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Choice of Refeeding Methods
Hart et al. [5] reviewed the literature to identify which of the different feeding methods is most ef- fective and advantageous in AN. An analysis of the published information revealed that the most common method of refeeding was by nasogastric feeding and food, followed by high-energy density oral nutritional supplements and food [5] . How- ever, due to the limited evidence available, no con- clusion could be drawn on the most effective meth- od of nutritional rehabilitation in AN. However, the authors compiled benefits and disadvantages of the different feeding methods for AN patients ( table 3 ). Similarly, Rocks et al. [6] concluded from their review of the available literature that a con- sensus on the most effective and safe treatment for weight restoration in inpatient children and ado- lescents with AN is not currently feasible. None- theless, these authors concluded that the use of tube feeding in addition to normal food intake in- creased energy intake and body weight, although it was associated with more frequent adverse effects.
A particular concern related to the use of na- sogastric tube feeding in malnourished patients is the risk of inducing refeeding syndrome with hypophosphataemia. Adaption to starvation in malnourished children and adolescents is associ- ated with a reduced metabolic turnover, cellular activity and organ function, low insulin secre- tion, and deficiencies in a variety of micronutri- ents, minerals and electrolytes [7] . Catabolic pa- tients use substrates from adipose tissue and muscle as sources of energy, and the total body stores of nitrogen, phosphate, magnesium and potassium become depleted. The sudden provi- sion of energy and nutrients reverses catabolism and leads to a surge of insulin secretion, which in turn leads to massive intracellular shifts of phos- phate, magnesium and potassium with a subse- quent fall in their serum concentrations. The clinical consequences of the resulting electrolyte disturbances with hypophosphataemia include haemolytic anaemia, muscle weakness and im- paired cardiac function, with the risks of fluid overload, cardiac failure, arrhythmia and death.
Table 3 (continued)
Benefits Disadvantages
Parenteral nutrition
– It requires minimal patient cooperation – It may reinforce a tendency to focus only on physical symptoms rather than the psychiatric implications of AN
– Sabotage occurs by pouring solutions into the sink and removing the device
– It cannot teach patients anything about eating, food choice or portion size, or about perceiving their bodies more accurately
– Medical complications [i.e. infections; arterial injury;
cardiac arrhythmias (from placement); changes in vascular endothelium; hyperosmolarity and hyperglycaemia; hypophosphataemia and hypokalaemia]
– More medically intensive, incurring high costs Modified from Hart et al. [5].
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
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7 Koletzko B, Goulet O: Nutritional sup- port in infants, children and adoles- cents; in Sobotka L (ed): Basics in Clini- cal Nutrition. Prague, Galén, 2011, pp 625–653.
8 O’Connor G, Nicholls D: Refeeding hy- pophosphatemia in adolescents with anorexia nervosa: a systematic review.
Nutr Clin Pract 2013; 28: 358–364.
9 Agostino H, Erdstein J, Di Meglio G:
Shifting paradigms: continuous naso- gastric feeding with high caloric intakes in anorexia nervosa. J Adolesc Health 2013; 53: 590–594.
References
1 Marzola E, Nasser JA, Hashim SA, Shih PA, Kaye WH: Nutritional rehabilitation in anorexia nervosa: review of the litera- ture and implications for treatment.
BMC Psychiatry 2013; 13: 290.
2 Weaver L, Sit L, Liebman R: Treatment of anorexia nervosa in children and ado- lescents. Curr Psychiatry Rep 2012; 14:
96–100.
3 American Psychiatric Association:
Treatment of patients with eating disor- ders, third edition. American Psychiat- ric Association. Am J Psychiatry 2006;
163(suppl):4–54.
4 National Institute for Health and Clini- cal Excellence: Eating Disorders. Man- chester, National Institute for Health and Clinical Excellence, 2004.
5 Hart S, Franklin RC, Russell J, Abraham S: A review of feeding methods used in the treatment of anorexia nervosa. J Eat Disord 2013; 1: 36.
6 Rocks T, Pelly F, Wilkinson P: Nutrition therapy during initiation of refeeding in underweight children and adolescent inpatients with anorexia nervosa: a sys- tematic review of the evidence. J Acad Nutr Diet 2014; 114: 897–907.
3 Nutritional Challenges in Special Conditions and Diseases
Key Words
Malignant disease ã Bone marrow/stem cell transplantation ã Mucositis ã Enteral tube feeding ã Parenteral nutrition
Key Messages
• Malnutrition is a common complication of malig- nant disease and its treatment, and is most likely to occur in advanced-stage solid tumours, acute my- eloblastic leukaemia and bone marrow/stem cell transplantation
• Nutritional support is a major part of therapy; there is no evidence that extra nutrients promote tumour growth
• The aims of nutritional support are to reverse mal- nutrition if present at diagnosis, to prevent deterio- ration in nutritional status during treatment, and to promote normal growth
• Children at low nutritional risk require high-energy supplements that can be taken by mouth; they ben- efit from flexibility in mealtimes and menus • When oral energy intake is inadequate, enteral tube
feeding should be used; this is usually well tolerat- ed and improves wellbeing even in children under- going intensive chemotherapy
• Parenteral nutrition is reserved for those children with severe gastrointestinal symptoms related to underlying disease, chemotherapy or radiotherapy
© 2015 S. Karger AG, Basel
Introduction
Nutritional status influences prognosis in chil- dren with cancer and affects treatment tolerance and susceptibility to infection. Patients often have significant difficulties with eating during long pe- riods of treatment and recurrent admissions to hospital, and have particular nutritional needs [1] . Malnutrition is common, with estimates of prevalence ranging up to 50% depending on the type, stage and metastatic status of the disease as well as the toxicity of various cancer therapies [2] . Children with large, solid abdominal masses (e.g.
neuroblastoma, hepatoblastoma, Wilms’ tu- mour) may present with normal weight despite severe nutritional depletion, so that simple an- thropometric assessment can be misleading [3] . The highest risk posed to nutritional status comes from advanced-stage solid tumours, acute my- eloid leukaemia, multiple-relapse leukaemia, head and neck cancer, medulloblastoma and bone marrow or stem cell transplantation. The pathophysiology of malnutrition is multifactorial and includes complex interactions between ener- gy and substrate metabolism, hormonal and in- flammatory components, and alterations of met- abolic compartments. These result in accelerated
Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 266–270 DOI: 10.1159/000360349