EATING DISORDER GUIDANCE NOTES
GUIDANCE NOTE 4a
DIETETIC RISK ASSESSMENT FOR REFEEDING
RECOMMENDED MEAL PLANS
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 www.nice.org.uk/CG032 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 0.5–1.0 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 on Adm. / Day 1 / Day 2 / Day 3 / Day 4 / Day 5 / Day 6 / Day 730 kg / 300 / 500 / 800 / 1000 / 1200 / 1400 / 1600
35 kg / 400 / 600 / 800 / 1000 / 1200 / 1400 / 1600
40 kg / 400 / 600 / 800 / 1000 / 1200 / 1400 / 1600
45 kg / 400 / 600 / 800 / 1000 / 1200 / 1400 / 1600
50 kg / 500 / 800 / 1000 / 1200 / 1400 / 1600 / 1600
55 kg / 500 / 800 / 1000 / 1200 / 1400 / 1600 / 1600
60 kg / 600 / 800 / 1000 / 1200 / 1400 / 1600 / 1600
- 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 on Adm. / Day 1 / Day 2 / Day 3 / Day 4 / Day 5 / Day 6 / Day 730 kg / 150 / 300 / 500 / 800 / 1000 / 1200 / 1400
35 kg / 200 / 400 / 600 / 800 / 1000 / 1200 / 1400
40 kg / 200 / 400 / 600 / 800 / 1000 / 1200 / 1400
45 kg / 200 / 400 / 600 / 800 / 1000 / 1200 / 1400
50 kg / 300 / 500 / 800 / 1000 / 1200 / 1400 / 1600
55 kg / 300 / 500 / 800 / 1000 / 1200 / 1400 / 1600
60 kg / 300 / 500 / 800 / 1000 / 1200 / 1400 / 1600
Step 3. Before and during the first 10 days of feeding:
- Oral thiamin 200–300 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 0.3–0.6 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)
Micronutrient Supplements:
- Micronutrient supplement recommended in both in-patients and out-patients
- 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 out-patients undergoing rapid weight gain
Suggested replacement therapy in a depleted patient:
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
Aneurin Bevan Local Health Board
Specialist ED Lead T&F Group
EATING DISORDER GUIDANCE NOTES
GUIDANCE NOTE 4a
DIETETIC RISK ASSESSMENT FOR REFEEDING
RECOMMENDED MEAL PLANS
Aneurin Bevan Local Health Board
Specialist ED Lead T&F Group