Riverside Adolescent Mental Health Unit Clinical Guidance for BrisDoc clinicians OOH
Care of the malnourished young person, including risk of re-feeding syndrome
(From Junior MARSIPAN Guidelines (Royal College of Psychiatrists 2015), and Refeeding Guidelines (Great Ormond Street Hospital).
MARSIPAN checklist for really sick patients with Anorexia Nervosa
Some patients on the Riverside Unit are significantly malnourished due to Anorexia Nervosa. The MARSIPAN checklist (see separate document on Toolkit) helps to guide the assessment of sick patients with Anorexia Nervosa. Do use this checklist to inform discussion with either the Consultant Psychiatrist on call, and/ or the medical team.
Re-feeding syndrome
This is a rare but potentially serious complication of commencing feeding in children and young people who have experienced starvation. It is characterised by:
- Clinical (cardiovascular and neurological)
- Biochemical abnormalities
When undernourished patients are re-fed there is an increased requirement for phosphate as the body switches back to carbohydrate metabolism, which can be potentiated by a background of relative phosphate depletion in starvation. Phosphate levels begin to fall, and cardiovascular and neurological sequelae may follow.
Signs and symptoms:
- Resting tachycardia
- Oedema or swelling, especially in the legs
- Confusion or altered conscious state (also check blood glucose level)
- Usually there is an associated low serum phosphate
Note the finding of resting tachycardia alone should prompt a medical review (including physical assessment, bloods and ECG, as below) and careful monitoring in the first instance (with consideration of other causes for tachycardia e.g. anxiety).
Risk factors:
- Very low weight (70-80% weight for height)
- Rapid weight loss (recent loss of 500g or more/week for 2 consecutive weeks)
- Minimal or no feeding prior to admission (acute food refusal or estimated calorie intake of less that 50% of expected, per day)
- Laxative use or vomiting
- Previous history of re-feeding syndrome
- Neutropenia on FBC
If re-feeding syndrome is suspected, please do the following:
- Full physical examination – heart rate, sitting and standing blood pressure, capillary blood glucose level (BM)
- Blood tests: FBC, phosphate, magnesium and electrolytes (see MARSIPAN checklist for guidance about interpreting the results)
- ECG (looking for abnormal QTc, bradycardia)
- Aged under 15 years (males and females) QTc is abnormal if >460ms
- Aged > 15 years of age QTc is abnormal is >450ms (males) and > 460ms (females)
Managing suspected re-feeding syndrome
If you suspect re-feeding syndrome, you will need to discuss with the medical consultant on call to discuss transferring the patient to the medical ward (or HDU/PICU depending on severity of clinical findings) at BCH or the BRI.
WDPL
NBT
If patient is acutely unwell with postural hypotension, collapse, hypokalaemia, hypoglycaemia, etc -> should come to 31A SS (please D/W AMU consultant first).
If stable but just needs re-feeding -> GP to refer to gastro SpR (via switch) to refer directly to gate 8a.