Acute Medical Stabilization: Focus on Nutritional Rehabilitation
Lorraine L McElwain, MD FAAP
May 14, 2011
Clinical Assessment:
Inadequate calories:
• Failure to gain weight, loss of weight, low BMI
• Low temp, low pulse, low BMR
• Loss of skin turgor, wrinkled and loose
• Loss of subcutaneous fat, loss from cheeks is last to occur
• Abd: distended or flat
• Hyptonia, muscle atrophy
• Listless, loss of appetite, “constipated”
• Limited attention
Inadequate protein:
• Failure to gain height, edema
• Loss of stamina, loss of muscle tissue/tone
• Loss of appetite
• Dermatitis-darker or dyspigmented
• Hair-sparse, color change, coarse
• Abd: distended (fatty liver, edema)
• Listless, lethargy, apathy, irritability
• Stupor, coma, death
Teens
• Prominence of bony protuberances
• Cold/blue hands/feet (acrocyanosis)
• Dry scaly skin
• Easy bruising
• Dry hair
• Lanugo (fine downy hair on back/abd/extrem)
• Dehydration/edema
• Scaphoid abdomen
Death and Anorexia Nervosa
• ~10% (0-6-10-20%) mortality rate
• Suicide – 50% (8X higher than general rate of young women), most attempts in AN w/ binge
eating and purging (1)
• Severe electrolyte disturbance
• Cardiac arrhythmia
• Congestive heart failure in recovery phase (related to rehydration and refeeding)
Indications for Hospitalization
• Severe malnutrition, wt < 75% of IBW
• Persistent weight loss, failure of catch-up growth
• Acute food refusal
• Vital sign abnormality (bradycardia, hypotension, symptomatic orthostasis, hypothermia)
• Acute medical disorder (dehydration, electrolyte abnormality, seizures, cardiac dysrhythmia)
• Acute psychiatric emergency (suicidal ideation, psychosis, AMS)
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Goals
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Need for further diagnostic & laboratory evaluation
for Acute Medical Hospitalization
Stabilize and normalize vital signs
Normalize electrolytes
Avoid CHF
Obtain sustained appropriate weight gain
Educate patient/parents on nutritional needs, seriousness of the disease
Establish clear discharge plan
Consider report to CPS
Laboratory Assessment
• Serum chemistries (sodium, phosphorous, potassium, magnesium, bicarbonate, glucose, BUN,
creatinine)
• CBC
27% anemia, 36% leukopenia, 17% neutropenia, 10% thrombocytopenia, 3% pancytopenia,
9% w/ severe infectious complication (2)
• LFTs (prealbumin, albumin, liver enzymes)
• Cholesterol, Triglycerides
• B12 and folate
• ESR
• Urinalysis
• Morning cortisol level
• Thyroid function tests
• Beta-HCG
• Prolactin
• LH & FSH, estradiol level
• Additional lab tests: based on Hx and PE
Other Assessments
• ECG (eval QTc, HR, voltages)
• ECHO (eval for effusion, cardiomyopathy, valve dysfunction, LV thickness)
• DEXA scan (if amenorrhic for > 6-12mos)
• Imaging (CXR, MRI-brain, BE, UGI with SBFT) based on clinical situation
• May need Hematology referral if pancytopenic (3)
• Psychosocial assessment and determination of other possible psychiatric comorbidities
Management – Nutritional Rehabilitation
• Correct dehydration
• Take a diet history, ask about licorice (4)
• Provide nutrition via NG tube (6) or oral with meal support therapy on a behavioral unit (7),
multivitamin, consider thiamine, consider fish oil (5)
• Start low, go slow, based on REE (8)
• Monitor for electrolyte abnormalities and refeeding syndrome, may need electrolyte replacement
• Monitor for cardiac arrhythmia
• Evaluate/treat GI complaints
• Evaluate for osteopenia
• Behavioral Interventions/Psychosocial Interventions/Treat underlying condition & comorbidities
• Interdisciplinary Team Approach - Thrive Team (for infants and younger children), Child
Psychiatry (for older children/teens)
Refeeding Syndrome
• Cardiovascular, neurological, and hematological complications that occur because of shifts in
phosphate, magnesium, or potassium from extracellular to intracellular space when changing
from a catabolic to an anabolic state
• Most common in pts with <75% IBW, low pre-albumin, low K or phos on admit
• In one study, 16% of AN patients had a low magnesium level on admission, 60% had a low
magnesium level during the admission, some reached nadir as late as third week of refeeding
(10)
• ¾ patients will have their phos nadir in first week (11)
• Will require close PE, laboratory, weight and vital sign monitoring
Cardiac Issues
• 60% with orthostatic pulse changes on admission, 85% with orthostatic pulse changes with
refeeding by day #4, mean # days before no longer orthostatic = 21 days +/- 11 days,
resolution occurred at 80.1 +/-5.7% IBW (12)
• Low heart rate and low BP is most worrisome if coexisting heart failure or arrhythmia
• MVP
GI Complaints
• Early satiety
• Abdominal pain
• Constipation (10% report laxative abuse, 20-30% have urine screen evidence of laxative abuse
(13))
• Bloating
References:
(1) Bulik et al, Suicide attempts in anorexia nervosa. Psychosomatic Medicine, April 2008, 70(3):378-383.
(2) Devuyst et al, Haematological changes and infectious complications in anorexia nervosa: a case-cohort study, Q J Med.
1993 Dec;86(12):791-9.
(3) Charania et al, Successful management of gelatinous transformation of the bone marrow in anorexia nervosa with
hematopoietic growth factors, International Journal of Eating Disorders, June 30 2010, EPub ahead of print
(4) Stoving et al, Is glycyrrhizin sensitivity increased in anorexia nervosa and should licorice be avoided? Case report and
review of the literature, Nutrition, Aug 24, 2010 EPub ahead of print
(5) Avraham et al, Fish oil promotes survival and protects against cognitive decline in severely undernourished mice by
normalizing satiety signals. The Journal of Nutritional Biochemistry, Nov 24 2010, EPub ahead of print
(6) Robb et al, Supplemental nocturnal nasogastric refeeding for better short-term outcome in hospitalized adolescent girls
with anorexia nervosa, Am J Psychiatry. 2002 Aug;159(8):1347-53.
(7) Couturier and Mahmood, Meal support therapy reduces the use of nasogastric feeding for adolescents hospitalized with
anorexia nervosa. Eating Disorders, July-Sept 2009, 17 (4), pp327-332
(8) Schebendach et al, The metabolic responses to starvation and refeeding in adolescents with anorexia nervosa. Annals
New York Academy of Sciences, 1997 May 28;817:110-9
(9) Lund et al, Rate of inpatient weight restoration predicts outcome in anorexia nervosa. International Journal of Eating
Disorders, May 24 2009, pp301-5
(10) Birmingham et al, Hypomagnesemia during refeeding in anorexia nervosa, Eating Weight Disorders. 2004 Sep;9 (3):
235-7.
(11) Katzman, Medical complications in adolescents with anorexia nervosa: a review of the literature. International Jounral of
Eating Disorders, 37:S52-S59, 2005
(12) Shamin et al, Resolution of vital sign instability: an objective measure of medical stability in anorexia nervosa, Journal of
Adolescent Health. 2003 Jan;32(1):73-77.
(13) Turner et al, Detection and importance of laxative use in adolescents with anorexia nervosa, Journal of American
Academic Child and Adolescent Psychiatry, March 2000,39(3):378-85.