Abstract
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.
Highlights
Anorexia Nervosa (AN) affects up to 0.5% of adolescents [1,2]
Benefits of these should be considered in parallel to the risk of refeeding syndrome (RS), a potentially lethal multi-systemic metabolic reaction triggered by increase in caloric intake in severely malnourished patients [40]
A systematic review by Garber et al concluded that evidence supported higher initial caloric intake (>1400 kcal/day) for mildly to moderately malnourished patient with AN, but highlighted the lack of evidence regarding those with severe malnutrition due to AN [17]
Summary
Anorexia Nervosa (AN) affects up to 0.5% of adolescents [1,2] It is considered the third most common chronic disease in adolescence and the psychiatric illness with the highest mortality rate, ranging from 2–8% [1,2]. Several clinical guidelines have established criteria for hospitalization of adolescents with AN including the Society for Adolescent Health and Medicine (SAHM) [4]. These criteria recommend admission for patients with significant underweight, defined as median BMI ≤ 75% for age and sex, acute medical or psychiatric complications and medical instability of which bradycardia is the most frequent in practice [4]
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