Assistance Publique-Hôpitaux de Paris, Service de Psychiatrie de l'Enfant et de l'Adolescent, Centre de Référence des Maladies Endocriniennes de la Croissance et du Développement, Hôpital Robert Debré, Paris, France.
Assistance Publique-Hôpitaux de Paris, Service d'Endocrinologie Diabétologie Pédiatrique, Centre de Référence des Maladies Endocriniennes de la Croissance et du Développement, Hôpital Robert Debré, Paris, France.
Eur J Pediatr. 2019 Mar;178(3):413-422. doi: 10.1007/s00431-018-3295-7. Epub 2018 Nov 27.
Refeeding in anorexia nervosa is a collaborative enterprise involving multidisciplinary care plans, but clinicians currently lack guidance, as treatment guidelines are based largely on clinical confidence rather than more robust evidence. It seems crucial to identify reproducible approaches to refeeding that simultaneously maximize weight recovery and minimize the associated risks, in addition to improving long-term weight and cognitive and behavioral recovery and reducing relapse rates. We discuss here various approaches to refeeding, including, among others, where, by which route, how rapidly patients are best refed, and ways of choosing between them, taking into account the precautions or the potential effects of medication or of psychological care, to define better care plans for use in clinical practice.Conclusion: The importance of early weight gain for long-term recovery has been demonstrated by several studies in both outpatient and inpatient setting. Recent studies have also provided evidence to support a switch in current care practices for refeeding from a conservative approach to higher calorie refeeding. Finally, the risks of undernutrition/"underfeeding syndrome" and a maintenance of weight suppression are now better identified. Greater caution should still be applied for more severely malnourished < 70% average body weight and/or chronically ill, adult patients. What is Known: • Refeeding is a central part of the treatment in AN and should be a multidisciplinary and collaborative enterprise, together with nutritional rehabilitation and psychological support, but there are no clear guidelines on the management of refeeding in clinical practice. • The risk of a refeeding syndrome is well known and well managed in severely malnourished patients ("conservative approaches"). What is New: • There is evidence that early weight restoration has an impact on outcome, justifying an aggressive approach to refeeding in the early stages of the illness. • The risks of "underfeeding syndrome" and of a maintenance of weight suppression are now better identified and there is sufficient evidence to support a switch in current care practices for refeeding from a conservative approach to higher calorie refeeding. Graphical abstract.
神经性厌食症的喂养恢复是一项涉及多学科护理计划的协作性工作，但临床医生目前缺乏指导，因为治疗指南主要基于临床信心，而不是更有力的证据。除了提高长期体重和认知及行为恢复以及降低复发率外，确定可重复的喂养方法至关重要，这些方法应同时最大限度地恢复体重，并最大限度地降低相关风险。我们在此讨论了各种喂养方法，包括患者应通过何种途径、以多快的速度最佳喂养，以及考虑到药物或心理护理的注意事项或潜在影响如何在这些方法之间进行选择，以便为临床实践制定更好的护理计划。结论：几项门诊和住院患者的研究已经证明了早期体重增加对长期恢复的重要性。最近的研究也提供了证据，支持将目前的喂养恢复护理实践从保守方法转变为更高热量的喂养。最后，现在更好地确定了营养不良/“喂养不足综合征”和体重抑制维持的风险。对于严重营养不良<70%平均体重和/或慢性疾病的成年患者，应更加谨慎。已知的：• 喂养恢复是 AN 治疗的核心部分，应作为多学科和协作的工作，与营养康复和心理支持一起进行，但临床实践中没有关于喂养管理的明确指南。• 严重营养不良患者的喂养恢复综合征风险众所周知且得到了很好的管理（“保守方法”）。新的发现：• 有证据表明早期体重恢复对结果有影响，这证明在疾病早期阶段采取积极的喂养恢复方法是合理的。• “喂养不足综合征”和体重抑制维持的风险现在得到了更好的识别，并且有足够的证据支持将目前的喂养恢复护理实践从保守方法转变为更高热量的喂养。图表摘要。
