A case of refeeding syndrome in pregnancy with anorexia nervosa

Refeeding syndrome very rarely develops during pregnancy. A 35-year-old primiparous woman pregnant with twins complained of severe fatigue at 19 weeks’ gestation. She was admitted to our hospital in a malnourished condition because of repeated self-induced vomiting due to anorexia nervosa. Just after hospitalization, she voluntarily increased her caloric intake significantly above the recommended prescribed diet, without medical permission. Nine days later, she developed refeeding syndrome. Electrolyte replacement and calorie restriction were started and her condition gradually improved. The healthy twin babies were born by cesarean section at 36 weeks’ gestation. Acute increases in caloric intake by previously malnourished pregnant women with anorexia nervosa may induce refeeding syndrome. Women with the binge eating/purging subtype of anorexia nervosa may be at additional risk due to alternating phases of starvation and overeating.

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Anorexia Nervosa—What Has Changed in the State of Knowledge about Nutritional Rehabilitation for Patients over the Past 10 Years? A Review of Literature

Nutrients ◽

10.3390/nu13113819 ◽

2021 ◽

Vol 13 (11) ◽

pp. 3819

Author(s):

Katarzyna Jowik ◽

Marta Tyszkiewicz-Nwafor ◽

Agnieszka Słopień

Keyword(s):

Anorexia Nervosa ◽

Healing Process ◽

Caloric Intake ◽

Current Treatment ◽

Review Of Literature ◽

Nutritional Rehabilitation ◽

Long Term Effects ◽

Refeeding Syndrome ◽

The Past ◽

Potential Benefits

Anorexia nervosa (AN) is a psycho-metabolic disorder with a high risk of somatic complications such as refeeding syndrome (RFS) and carries the highest mortality rate of all psychiatric illnesses. To date, the consensus on the care for patients with AN has been based on recommendations for a combination of alimentation and psychotherapy. It is important to establish an initial caloric intake that will provide weight gain and minimize the risk of complications in the treatment of undernourished patients. Research over the past few years suggests that current treatment recommendations may be too stringent and should be updated. The aim of this paper is to systematize the current reports on nutritional rehabilitation in AN, to present the results of studies on the safe supplementation of patients and its potential impact on improving prognosis and the healing process. This review of literature, from 2011–2021, describes the changing trend in the nutritional protocols used and the research on their efficacy, safety, and long-term effects. In addition, it presents previous reports on the potential benefits of introducing vitamin, pro-and prebiotic and fatty acid supplementation.

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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

Journal of Adolescent Health ◽

10.1016/j.jadohealth.2013.05.014 ◽

2013 ◽

Vol 53 (5) ◽

pp. 573-578 ◽

Cited By ~ 62

Author(s):

Neville H. Golden ◽

Casey Keane-Miller ◽

Kristin L. Sainani ◽

Cynthia J. Kapphahn

Keyword(s):

Anorexia Nervosa ◽

Length Of Stay ◽

Caloric Intake ◽

Refeeding Syndrome

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To Improve the Initial Inpatient Management of Adolescents Admitted with Severe Anorexia Nervosa: A Narrative Review and a Convenient Protocol

Nutrients ◽

10.3390/nu14010229 ◽

2022 ◽

Vol 14 (1) ◽

pp. 229

Author(s):

Stephanie Proulx-Cabana ◽

Marie-Elaine Metras ◽

Danielle Taddeo ◽

Olivier Jamoulle ◽

Jean-Yves Frappier ◽

...

Keyword(s):

Anorexia Nervosa ◽

Caloric Intake ◽

Tube Feeding ◽

Narrative Review ◽

Cardiac Monitoring ◽

Current Evidence ◽

Cardiac Complications ◽

Nutritional Rehabilitation ◽

Refeeding Syndrome ◽

Pubmed Search

Inadequate nutritional rehabilitation of severely malnourished adolescents with Anorexia Nervosa (AN) increases the risk of medical complications. There is no consensus on best practices for inpatient nutritional rehabilitation and medical stabilization for severe AN. This study aimed to elaborate an admission protocol for adolescents with severe AN based on a comprehensive narrative review of current evidence. A Pubmed search was conducted in July 2017 and updated in August 2020, using the keywords severe AN or eating disorders (ED), management guidelines and adolescent. Relevant references cited in these guidelines were retrieved. A secondary search was conducted using AN or ED and refeeding protocol, refeeding syndrome (RS), hypophosphatemia, hypoglycemia, cardiac monitoring or cardiac complications. Evidence obtained was used to develop the admission protocol. Selective blood tests were proposed during the first three days of nutritional rehabilitation. Higher initial caloric intake is supported by evidence. Continuous nasogastric tube feeding was proposed for patients with a BMI < 12 kg/m2. We monitor hypoglycemia for 72 h. Continuous cardiac monitoring for bradycardia <30 BPM and systematic phosphate supplementation should be considered. Developing protocols is necessary to improve standardization of care. We provide an example of an inpatient admission protocol for adolescents with severe AN.

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Faculty Opinions recommendation of Higher caloric intake in hospitalized adolescents with anorexia nervosa is associated with reduced length of stay and no increased rate of refeeding syndrome.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.718048371.793481119 ◽

2013 ◽

Author(s):

Debra Katzman

Keyword(s):

Anorexia Nervosa ◽

Length Of Stay ◽

Caloric Intake ◽

Refeeding Syndrome

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Metabolic and Nutritional Needs to Normalize Body Mass Index by Doubling the Admission Body Weight in Severe Anorexia Nervosa

Clinical Medicine Insights Case Reports ◽

10.4137/ccrep.s11471 ◽

2013 ◽

Vol 6 ◽

pp. CCRep.S11471 ◽

Cited By ~ 4

Author(s):

Maria Gabriella Gentile ◽

Chiara Lessa ◽

Marina Cattaneo

Keyword(s):

Body Weight ◽

Anorexia Nervosa ◽

Clinical Laboratory ◽

Psychiatric Patients ◽

Caloric Intake ◽

Tube Feeding ◽

Young Female ◽

Refeeding Syndrome ◽

Nutritional Needs ◽

Electrolyte Abnormalities

Anorexia nervosa exhibits one of the highest death rates among psychiatric patients and a relevant fraction of it is derived from undernutrition. Nutritional and medical treatment of extreme undernutrition present two very complex and conflicting tasks: (1) to avoid “refeeding syndrome” caused by a too fast correction of malnutrition; and (2) to avoid “underfeeding” caused by a too cautious refeeding. To obtain optimal treatment results, the caloric intake should be planned starting with indirect calorimetry measurements and electrolyte abnormalities accurately controlled and treated. This article reports the case of an anorexia nervosa young female affected by extreme undernutrition (BMI 9.6 kg/m2) who doubled her admission body weight (from 22.5 kg to 44 kg) in a reasonable time with the use of enteral tube feeding for gradual correction of undernutrition. Refeeding syndrome was avoided through a specialized and flexible program according to clinical, laboratory, and physiological findings.

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Avoiding Refeeding Syndrome in Anorexia Nervosa

10.26226/morressier.588f064ed462b8028d891148 ◽

2017 ◽

Author(s):

Diana Brigadeiro

Keyword(s):

Anorexia Nervosa ◽

Refeeding Syndrome

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Higher Caloric Refeeding Is Safe in Hospitalised Adolescent Patients with Restrictive Eating Disorders

Journal of Nutrition and Metabolism ◽

10.1155/2016/5168978 ◽

2016 ◽

Vol 2016 ◽

pp. 1-9 ◽

Cited By ~ 12

Author(s):

Elizabeth K. Parker ◽

Sahrish S. Faruquie ◽

Gail Anderson ◽

Linette Gomes ◽

Andrew Kennedy ◽

...

Keyword(s):

Eating Disorders ◽

Weight Gain ◽

Statistical Significance ◽

Caloric Intake ◽

Tube Feeding ◽

Retrospective Chart Review ◽

Refeeding Syndrome ◽

Restrictive Eating ◽

Weight Restoration ◽

The Mean

Introduction. This study examines weight gain and assesses complications associated with refeeding hospitalised adolescents with restrictive eating disorders (EDs) prescribed initial calories above current recommendations.Methods. Patients admitted to an adolescent ED structured “rapid refeeding” program for >48 hours and receiving ≥2400 kcal/day were included in a 3-year retrospective chart review.Results. The mean (SD) age of the 162 adolescents was 16.7 years (0.9), admission % median BMI was 80.1% (10.2), and discharge % median BMI was 93.1% (7.0). The mean (SD) starting caloric intake was 2611.7 kcal/day (261.5) equating to 58.4 kcal/kg (10.2). Most patients (92.6%) were treated with nasogastric tube feeding. The mean (SD) length of stay was 3.6 weeks (1.9), and average weekly weight gain was 2.1 kg (0.8). No patients developed cardiac signs of RFS or delirium; complications included 4% peripheral oedema, 1% hypophosphatemia (<0.75 mmol/L), 7% hypomagnesaemia (<0.70 mmol/L), and 2% hypokalaemia (<3.2 mmol/L). Caloric prescription on admission was associated with developing oedema (95% CI 1.001 to 1.047;p=0.039). No statistical significance was found between electrolytes and calories provided during refeeding.Conclusion. A rapid refeeding protocol with the inclusion of phosphate supplementation can safely achieve rapid weight restoration without increased complications associated with refeeding syndrome.

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Endometriosis and Risk of Adverse Pregnancy Outcome: A Systematic Review and Meta-Analysis

Journal of Clinical Medicine ◽

10.3390/jcm10040667 ◽

2021 ◽

Vol 10 (4) ◽

pp. 667

Author(s):

Kjerstine Breintoft ◽

Regitze Pinnerup ◽

Tine Brink Henriksen ◽

Dorte Rytter ◽

Niels Uldbjerg ◽

...

Keyword(s):

Preterm Birth ◽

Cesarean Section ◽

Placental Abruption ◽

Gestational Hypertension ◽

Adverse Pregnancy Outcome ◽

Placenta Previa ◽

Meta Analysis ◽

Increased Risk ◽

Spontaneous Hemoperitoneum ◽

In Pregnancy

Background: This systematic review and meta-analysis summarizes the evidence for the association between endometriosis and adverse pregnancy outcome, including gestational hypertension, pre-eclampsia, low birth weight, and small for gestational age, preterm birth, placenta previa, placental abruption, cesarean section, stillbirth, postpartum hemorrhage, spontaneous hemoperitoneum in pregnancy, and spontaneous bowel perforation in pregnancy. Methods: We performed the literature review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA), by searches in PubMed and EMBASE, until 1 November 2020 (PROSPERO ID CRD42020213999). We included peer-reviewed observational cohort studies and case-control studies and scored them according to the Newcastle–Ottawa Scale, to assess the risk of bias and confounding. Results: 39 studies were included. Women with endometriosis had an increased risk of gestational hypertension, pre-eclampsia, preterm birth, placenta previa, placental abruption, cesarean section, and stillbirth, compared to women without endometriosis. These results remained unchanged in sub-analyses, including studies on spontaneous pregnancies only. Spontaneous hemoperitoneum in pregnancy and bowel perforation seemed to be associated with endometriosis; however, the studies were few and did not meet the inclusion criteria. Conclusions: The literature shows that endometriosis is associated with an increased risk of gestational hypertension, pre-eclampsia, preterm birth, placenta previa, placental abruption, cesarean section, and stillbirth.

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