GUIDANCE NOTES. DIETETIC RISK ASSESSMENT FOR REFEEDING RECOMMENDED MEAL PLANS When commencing re-feeding: NICE (2006)

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1 When commencing re-feeding: NICE (2006) NICE (2006) Clinical Guideline 32 Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition (The following is based on available from web site) Remember: - Oral feeding is simpler and safer than artificial methods - Give small amounts frequently (3-4 hourly) - Intake should be limited at first and increased slowly - Weekly weight gain of kg generally regarded as optimum Step 1. Decide whether patient is at high or normal risk of re-feeding: The patient is at high risk if they have One or more of the following: - BMI less than 16 kg/m2 - Unintentional weight loss greater than 15% within the last 3 6 months - little or no nutritional intake for more than 10 days - low levels of potassium, phosphate or magnesium prior to feeding. Two or more of the following: - BMI less than 18.5 kg/m2 - Unintentional weight loss greater than 10% within the last 3 6 months - little or no nutritional intake for more than 5 days - a history of alcohol abuse or drugs including insulin, chemotherapy, antacids or diuretics. Step 2. Decide rate of re-feeding: - If normal risk, start nutrition support at a maximum of 10 kcal/kg/day, increasing levels slowly to meet or exceed full needs by 4 7 days (see sample meal plans) If normal risk: number of kcals to be given / day: Weight Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 on Adm. 30 kg kg kg kg kg kg kg

2 - If high risk, commence feeding at only 5 kcal/kg/day in extreme cases (see sample meal plans) - Restore circulatory volume and monitoring fluid balance and overall clinical status closely If High risk: number of kcals to be given / day: Weight Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 on Adm. 30 kg kg kg kg kg kg kg Step 3. Before and during the first 10 days of feeding: - Oral thiamin mg daily, - Vitamin B co strong 1 or 2 tablets, three times a day (or full dose daily intravenous vitamin B preparation, if necessary) (i.e one pair of Pabrinex IV high potency ampoules. Ensure facilities for treating anaphylylaxis are available during administration). - A balanced multivitamin/trace element supplement once daily e.g. Forceval 1 x capsule daily - Provide oral, enteral or intravenous supplements of potassium (likely requirement 2 4 mmol/kg/day), phosphate (likely requirement mmol/kg/day) and magnesium (likely requirement 0.2 mmol/kg/day intravenous, 0.4 mmol/kg/day oral) unless pre-feeding plasma levels are high. - Pre-feeding correction of low plasma levels is unnecessary. Step 4. Correction of Electrolyte Disturbances: (see over) - Biochemical monitoring should guide need for replacement - Electrolytes may change rapidly during first week - Can be replaced orally or intravenously (if absolutely necessary and with caution) - Electrolytes are closely inter-related - Hypo-magnesaemia may cause hypo-kalaemia - Replacement of phosphate may cause calcium to drop Detailed guidance on electrolyte replacement in: Guidelines for the nutritional management of anorexia nervosa (Royal College of Psychiatrists, 2005)

3 Micronutrient Supplements: - Micronutrient supplement recommended in both in-patients and outpatients - Forceval or Sanatogen Gold (non-nhs) - Compound preparations may not contain enough thiamin to meet metabolic demands of re-feeding - Oral thiamin (25-50 mg/day) recommended for in-patients and outpatients undergoing rapid weight gain Suggested replacement therapy in a depleted patient: Phosphate Correction If <0.30mmol/l and renal function/ calcium levels are normal, correct using Phosphate Polyfusor (contains 50mmol phosphate in 500mls). Maximum rate of 9mmol of phosphate over 12hrs (faster rates may be given in ITU), therefore 90ml of Phosphate Polyfusor in 12hrs, administer at 7.5ml/hour (total of 180mls). Re-check phosphate levels daily and repeat above infusion if levels remain <0.30mmol/l. If levels are between 0.30mmol/l - 0.5mmol/l, administer 3 tablets daily (maximum) of Phosphate-Sandoz via the enteral route. Potassium Correction If < 3mmol/l, correct using 1litre of saline and 40mmol of K per litre, over a minimum of 2 hours If levels are between 3-3.5mmol/l, administer Sando K, one tablet three times a day. Magnesium Correction If <0.5mmol/l, correct using 10ml of Magnesium Sulphate 50% (contains 20mmol magnesium) in 100ml of suitable fluid (e.g. sodium chloride 0.9%) over a minimum of 2½ hours. Oral preparations are generally not recommended due to tolerance and side effects of large doses. Average deficit in symptomatic magnesium deficiency is 1mmol/kg (can replace up to 50mmol a day). Monitor levels and repeat once daily until levels >0.5mmol/l.

4 Step 5. Feed as per meal plan. - Contact Dietitian if there are any problems, questions or if you would like any further information re: the above Step 6. Dietitian will aim to review patient in person as soon as possible

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6 Time Frame for Re-feeding Treat or prevent: Hypoglycaemia Hypothermia Dehydration Correct electrolyte imbalance Days 1-2 Days 3-7 Weeks 2-6 Weeks 7 Correct micronutrient deficiencies Begin feeding Increase feeding to recover lost weight without iron with iron