Refeeding Low Weight Adolescents with AN

Transcription

1 RCPsych ED 2013 Refeeding Low Weight Adolescents with AN Graeme O Connor RD PhD Research Student -UCL Specialist paediatric Dietitian Great Ormond Street Hospital Foundation Trust

2 Pathophysiology of starvation 1- Insufficient energy insulin glucagon 3- Activation of hormone sensitive lipase. 5- Fatty acids +glycerol delivered to the liver ketone production 7- Shift to ketone and glucose metabolism 9- Muscle wasting amino acid production 2- Depleted glycogen stores in muscles and liver 4- Adipose tissue breakdown 6- Gluconeogenesis Amino acid and glycerol = glucose Brain, retina and nephrons 8- Serum electrolytes maintained: Bone and tissue catabolism Increased renal tubular reabsorption Dehydration 10- Autonomic nervous system disturbances bradycardia, QT Interval prolongation.

3 Perceived Risk factors of RS - Rate of weight loss prior to refeeding (Crook, Hally et al. 2001; Boateng, Sriram et al. 2010; Raj, Keane-Miller et al. 2012); - The extent of malnutrition (Ornstein, Golden et al. 2003; Raj, Keane-Miller et al. 2012); - Method of refeeding (enteral verse Parenteral)(Weinsier and Krumdieck 1981; Diamanti, Basso et al. 2008); - Carbohydrate load (Kohn, Madden et al. 2011; O'Connor and Goldin 2011); - Rate at which nutrition is introduced (Kohn, Golden et al. 1998; Whitelaw, Gilbertson et al. 2010). - The rate at which nutrition is introduced has received much attention and tends to be the focal point of refeeding guidelines (Golden, Katzman et al. 2003; NICE February 2006; RCP July 2005).

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5 Literature Review Refeeding malnourished children Author/ Country Age Kcal/ kg Calculated intake for a 30kg child Australia/ WHO < kcal USA/ Canada 2006/08 < kcal UK MARSIPAN - NICE Junior - MARSIPAN 2012 Adult Adult < kcal kcal European Stanga 2008 Adult kcal

6 Research Proposal Aim Identify whether there is a correlation between energy intake and cardiovascular, biochemical and anthropometric outcomes: Outcome Measure - Cardiovascular QTc interval/ QT dispersion/ HR - Biochemical - PO4, K, Ca, Mg, FBC - Anthropometrics Weight/ %BMI Identify potential predictive markers for the refeeding Hypophosphatemia. Develop International evidence based refeeding guidelines

7 Methodology Inclusion criteria DSM IV Restrictive anorexia nervosa <75%mBMI (healthy %) Weight losing trajectory ( >0.2kg/ week) Admission to paediatric unit Randomisation: Control group 500kcal/ day y( (10-20kcal/ kg) low calorie Treatment group 1200kcal/ day (30-40kcal/ kg) high calorie stratification for %BMI and feeding route (oral or enteral) (SIMS computer programme) 36 participants recruited over 2years

8 Methodology - Once randomised - 200kcal increments daily until at 80% of EAR ( kcal/ day) meal plan templates. - Thiamine 200mg/ day from day 1 - ECG 12 lead (on day 1 and 4) - Fasting biochemistry inc insulin, glucose, FBC (day 1,2,4,6,10) - Vital signs HR, BP, Temp (4 x daily)

9 Day 4 Mean diff 0.4kg (P=0.06; CI -0.9,0.03) Day 10 Mean Diff 0.5kg (95% CI -1.1, 0.1kg; P=0.09)

10 QT Interval

11 QTc interval >440ms Event 500KCAL 1200KCAL QTc interval prolongation Baseline 3 2 QTc interval prolongation (post feeding) 2 1 Total Refed Odds Ratio 0.5 (95% CI 0.04, 5)

12 Hypophosphatemia <0.8mmol/ l Event 500KCAL 1200KCAL Hypophosphatemia (<0.8mmol/l) 2 5 Total Refed Odds Ratio 3 (95% CI 0.5, 18)

13 Relationship between energy intake and post feeding phosphate

14 %mbmi Marker for RH For every 1% decrease in mbmi serum PO4 drops by (P=0.03; 03; 95%CI to 0.039mmol/l)

15 WBC marker for RH For every 1x drop in WBC, serum PO4 values were on average 0.1mmo/l lower with a 95% CI 0.02, 0.2; P=0.01

16 Mechanisms contributing to RH

17 Refeeding recommendations Refeeding malnourished adolescents with AN at 1200kcal/ day y( (30-40kcal/ kg) elicits greater weight gain and had no adverse effect on cardiac function. No association between energy intake or carbohydrate intake was linked to refeeding hypophosphatemia. Patients that are very low weight <70%BMI may be at increased risk of developing refeeding hypophosphatemia. Patients that have low WBC s <3.8 x 10 9 /L may be at increased risk of developing refeeding hypophosphatemia (caveat raised CRP). Patients at higher risk of refeeding complications should commence prophylactic phosphate at 2-3mmol/ kg (phosphate sandoz =16mmol)

18 References Afzal NA, Addai S, Fagemi S and Heuschkel R. (2002) Refeeding Syndrome with enteral nutrition in children: a case report, literature review and clinical guidelines. Clinical Nutrition. 21(6): Clark C, Sacks G, Dickerson D, and Brown R. (1995) Treatment of hypophosphatemia in patients receiving specialized nutrition support using a graduated dosing scheme: result from a prospective clinical trial. Critical Care Medicine. 23(9): Crook MA, Hally V & Panteli JV. (2001) the importance of the refeeding syndrome. Nutrition. 17(7): Fisher M, Simper E & Schneider M. (2000) Hypophosphatemia secondary to oral refeeding in anorexia nervosa. International journal of eating disorders. 28(2): Garrow JS, James WPT and Ralph A. Human Nutrition and Dietetics (10th Edition). Church Livingstone 2002 Hamilton Jan. (2007) Eating Disorders in Pre-adolescents. The Nurse Practitioner. 32(3): Isner JM, Roberts WC, Heymsfield SB & Yager J. (1985) Anorexia nervosa and sudden death. Annuals International Medicine. i 102(1): Katzman DK. (2005) Medical complications in adolescents with anorexia nervosa: A review of the literature. International journal of eating disorders. 37(4): S52-S59.

19 Keys A, Henschel A & Taylor HL. (1947) the size and function of the heart at rest in semi starvation and in subsequent rehabilitation. American journal of physiology. 150(1): Kohn M, Golden N & Shenker R. (1998) Cardiac arrest and delirium: Presentations of the refeeding syndrome in severely malnourished adolescents with anorexia nervosa. Journal of Adolescent Health. 22(3): Metz R. (1960) The effect of blood glucose concentration on Insulin Output. Diabetes. 9(1): Ornstein RM, Golden NH, Jacobson MS& Shenker R. (2003) Hypophosphatemia during nutritional rehabilitation in anorexia nervosa: Implications for refeeding and monitoring. Journal of Adolescent Health. 32(1): Solomom SM & Kirby DF. (1990). The refeeding syndrome: A Review. Journal parenteral and enteral nutrition. 14(1): Schofield WN (1985). Predicting Basal Metabolic Rate, New Standards and Review of Previous Work. Hum Nut Clin Nut. 39(Supp 1): 5-41 Nutritional support in adults: oral nutritional support, enteral tube feeding and parenteral nutrition. February Clinical Guidelines 32. National Institute of Clinical Excellence. Refeeding Syndrome: Guidelines. (March 2007) Cape Town Metropole Paediatric Interest Group World Health Organisation, Geneva. (1999) Management of severe malnutrition: a manual for physicians and senior health workers. ISBN (WD101)