Pediatric patients with anorexia nervosa and atypical anorexia nervosa may present to hospitals with significant vital sign instability or serum laboratory abnormalities necessitating inpatient medical hospitalization. These patients require specialized care, numerous resources, and interdisciplinary collaboration during what can be a protracted admission. Recent evidence informs areas in which care can be accelerated, and published protocols from major children’s hospitals are helpful roadmaps to creating a streamlined hospitalization. In our narrative review, we focused on 3 key areas: (1) implementation of a rapid nutritional rehabilitation program; (2) assessment and management of the refeeding syndrome; and (3) early integration of psychoeducation and therapeutic interventions during inpatient hospitalization. A practical review of the literature in these 3 areas will give concrete, actionable information to pediatric hospitalists as they care for young people with restrictive eating disorders.
Young people struggling with restrictive eating disorders may present to children’s hospitals with signs of physiologic instability secondary to malnutrition, necessitating inpatient medical admission.1 These disorders must be framed as life-threatening because of high mortality rates from medical and psychological complexity.2,3 Additionally, length of stay and diagnosis-specific mean costs are higher for eating disorder admissions compared with other behavioral health admissions to freestanding children’s hospitals.4
A 2015 position article from the Society for Adolescent Health and Medicine provides timely guidance for pediatricians who care for young people with restrictive eating disorders, including the medical criteria warranting inpatient hospitalization.5 More recent evidence posits nutritional, medical and therapeutic interventions to accelerate the treatment and recovery process while hospitalized. These interventions not only decrease length of hospitalization, but also lead to improved short- and long-term outcomes in disease course. In this review, we summarize these evidence-based accelerants in the context of inpatient nutritional rehabilitation, diagnosis and management of the refeeding syndrome, and practical inclusion of therapeutic language.
Diagnostic Considerations
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition defines anorexia nervosa (AN) as the restriction of energy intake leading to a body weight that is significantly lower than expected, with an intense fear of gaining weight or persistent behaviors that interfere with weight gain.6 The approach to screening and diagnosis of restrictive eating disorders has changed since atypical anorexia nervosa (AAN) was recognized as a diagnosis. Patients with AAN share eating disorder psychopathology congruent to patients with AN, but, despite significant weight loss, they are not considered underweight relative to normative growth standards.6 Extrapolating from the diagnostic criteria within the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition and the clinical guidelines for classifying malnutrition published by the Society for Adolescent Health and Medicine, AAN is typically diagnosed in adolescents when when BMI is ≥90% median BMI (mBMI) at presentation, with weight loss of ≥10% body weight.5,6 For the purposes of this article, restrictive eating disorder refers to both AN and AAN.
When compared with underweight patients with AN, adolescents with AAN showed no significant differences in the frequency of bradycardia or orthostatic instability and, in fact, experienced worse eating disorder psychopathology.7,8 Subsequent studies of adolescents with AAN revealed that those admitted to the hospital with greater amount, rate, or duration of weight loss correlated with more severe medical complications, independent of admission weight.8,9 These findings underscore the importance of obtaining a detailed weight history on admission and rejecting the traditionally held notion that lower weight equates to more severe illness.8
Medical Refeeding Protocols
Medical refeeding, also called nutritional rehabilitation, is a crucial first step in the treatment of medically unstable patients with restrictive eating disorders. Strategic implementation of new evidence for aggressive caloric progression, medical monitoring, oversight of physical activity, and auxiliary feeding strategies can decrease the average length of hospitalization from 17 days to 11 to 13 days.1,10–12 Speeding the process of acute nourishment safely brings medical and psychological benefits, alongside decreased hospitalization costs.13,14 Various institutions have published their pediatric refeeding protocols and safety data to shed light on best practices.1,15–17 Although evidence to guide strict protocols for medical monitoring, physical activity levels, and strategies for auxiliary feeding do not exist, each component is requisite when creating a protocol for these patients (Table 1).
Higher-Calorie Approaches
The urgency of weight restoration and nutritional replenishment cannot be understated. Balancing the dire need for weight gain with the medical risk of the refeeding syndrome, conservative inpatient nutritional rehabilitation programs were traditionally implemented with slow progression of daily caloric intake.1,17,18 As a result, lengthy inpatient medical hospitalizations delayed initiation of therapeutic interventions for the sake of medical stability. Emerging evidence from studies with adult eating disorder populations details an equally dangerous “underfeeding syndrome,” characterized by slow achievement of nutritional goals, high rates of relapse, premature withdrawal from treatment, and even death, underscoring the need for accelerated nutrition protocols.19
Higher-calorie approaches have challenged the standard, resulting in shorter lengths of stay and quicker initiation of outpatient therapeutic care, without increased incidence of the refeeding syndrome.11,12,17,20–22 Not only does this provide value incentive without compromising patient safety, but early and aggressive weight gain in treatment also positively predicts remission from illness and global improvement in eating disorder pathology.23,24 Recently published, the first randomized controlled trial (RCT) comparing higher- and lower-calorie refeeding protocols revealed a quicker restoration of medical stability in the higher-calorie refeeding group without an increase in safety events.21 In this RCT, higher-calorie refeeding began at 2000 kcal/day and increased by 200 kcal/day, whereas lower-calorie refeeding began at 1400 kcal/day and increased by 200 kcal every other day.21 Several other institutions have revealed that starting with a higher caloric load and progressing rapidly under close medical supervision is safe and promotes accelerated weight restoration, with evidence of improved short- and long-term disease course.15,17,21,23,24 Collectively, this evidence heralds a new standard in the field.
The Society for Adolescent Health and Medicine says inpatient weight gain should fall between 1 and 2 kg per week.5 Of note, standard of care for those presenting with severe malnutrition (BMI ≤70% mBMI) remains initiation of lower-calorie meal plans with slow advancement.20 Explicit, evidence-based guidelines to define lower-calorie refeeding protocols do not exist, although, in a study of severely underfed adult and adolescent patients with AN, average initial caloric intake was 1199 kcal/day.25 Another retrospective chart review comparing caloric approaches specified the “lower-calorie group” as those patients started on <1400 kcal/day.10 There are insufficient data to recommend more aggressive approaches at this time, and further study into the safety and efficacy of higher-calorie refeeding in the severely malnourished population is warranted.
Monitoring and Activity Restriction
Consensus guidelines for inpatient medical monitoring and advancement of activity level do not yet exist, although published refeeding protocols from major pediatric medical centers use both. Protocols can be discussed with families before initiation because anticipatory guidance helps decrease resultant distress.26 Medical monitoring generally includes serum electrolytes, continuous cardiopulmonary monitoring, daily premeal, postvoid, and gowned weight; daily orthostatic vital signs; and strict intake and output monitoring.1,15 Because complete normalization of vital signs occurs closer to full weight restoration, this threshold may not occur while inpatient.27 Orthostatic pulse change tends to take longer than other vital sign abnormalities to resolve, with 1 study citing ≥3 weeks.27 Monitoring vitals while inpatient helps establish trends or anticipate adverse events rather than establish a complete return to baseline. Studies of cardiac abnormalities in young people with AN compared with healthy peers reveal a significantly increased incidence of bradycardia and prolonged QTc intervals, placing them at risk for ventricular arrhythmias and sudden death. Although explicit cardiac monitoring guidelines based on risk stratification do not exist, protocols from various children’s hospitals provide a helpful schema for the frequency and intensity of cardiac monitoring.1,12,16 In addition to post-meal visual monitoring to reduce the risk of purging, activity is generally restricted during the initial period of inpatient refeeding to avoid additional overt or covert energy expenditure and to prevent injury due to medical fragility.1,28
Alternative Renourishment Strategies
Weight restoration strategies must be quickly modified for those patients who are unable to meet caloric goals with volitional solid food intake, although there is marked heterogeneity in how this is accomplished and no definitive approach based on evidence. A common first-line option is high-calorie supplement beverages, taken orally, to replace the portion of the meal that is not consumed.1,16,20 Options for acute refusal of oral intake include use of a nasogastric (NG) tube at mealtimes, and overnight NG feedings.20 Limited studies have revealed accelerated weight gain with initial NG feeds regardless of ability to take food orally, although there is insufficient evidence to recommend this approach over an initial trial of meal-based refeeding.12,28,29 NG tube placement may be used when the young person fails to volitionally consume prescribed calories (either by meal or by high-calorie supplemental beverage). Total parenteral nutrition is rarely recommended because of its high risk for medical complications.20,30 Ultimately, a successful transition to calorie-dense, nutritionally varied oral intake predicts positive long-term outcomes.31,32
Medications
Although psychotropic medication is often used in the setting of AN and AAN, surprisingly few data exist to support its use in adolescents.33 In cases in which data exist, conclusions must be interpreted with caution owing to small sample sizes, inherent biases of the sample population, and the limited use of control groups. Olanzapine is the most frequently studied, with 1 double-blind, placebo-controlled trial that did not yield beneficial effects on weight restoration.34 A number of open trials and retrospective case series with the second-generation antipsychotics have reported higher rates of weight gain, improved global functioning, and decreases in psychopathology related to the eating disorder.35–38
Even fewer studies of the selective serotonin reuptake inhibitors (SSRIs) exist for the treatment of adolescent AN and AAN, with no placebo-controlled trials to date. Retrospective studies with the SSRIs did not reveal improvements in BMI, eating disorder psychopathology, or weight phobia.39,40 Additionally, studies of underweight adult patients reveal deficits in the production of serotonin and serotonin metabolites, and the SSRIs depend on neuronal release of serotonin to exert effect.41 The benzodiazepines have not been studied in adolescents. In a double-blind, placebo-controlled crossover study of adult inpatients with AN, alprazolam did not reduce anxiety nor yield increased caloric intake.42 Any potential benefit from these medication classes must also be weighed against the inherent risks of adverse effects. Given the limited evidence for pharmacotherapy, psychotropic medications are unlikely to be of acute benefit during the period of medical instability and unlikely to yield improvements that will meaningfully accelerate the hospital course.
The Refeeding Syndrome
Definition
Whereas clinical practice continues to shift to higher-calorie refeeding protocols, this more aggressive approach must be balanced against the risk of developing the refeeding syndrome. The refeeding syndrome is characterized by the severe electrolyte abnormalities, metabolic changes, and fluid shifts in malnourished patients undergoing refeeding, leading to potentially severe and even fatal complications.47 The constellation of symptoms may present within days to weeks of initiation of refeeding.48 Incidence of the refeeding syndrome in hospitalized adolescents with AN and AAN is difficult to ascertain because of the lack of standardized refeeding protocols and lack of clear consensus on management of this syndrome. One systematic review of hospitalized adolescents with AN found an average incidence of refeeding hypophosphatemia (RH) to be 14%.49 RH is an easily measured surrogate marker of the refeeding syndrome and the most consistently reported, although hypokalemia, hypomagnesemia, hypoglycemia, and fluid shifts are other crucial findings.48,50–52
Physiology
In starvation, fat and protein are catabolized to produce energy. When refeeding begins, the body transitions to carbohydrate metabolism, which releases insulin, driving an influx of phosphorous, potassium, glucose, and other electrolytes into cells.50 Phosphate is critical to the production of adenosine triphosphate, which provides energy to many organ systems.53 This extracellular depletion of phosphate, coupled with the high demand for phosphorylated intermediates to produce energy, leads to derangement in metabolic processes across all organ systems. Unsurprisingly, hypophosphatemia can present with a myriad of clinical features, including impaired myocardial contractility, ventricular arrhythmia, respiratory failure, muscular dysfunction, rhabdomyolysis, confusion, seizures, neuropathy, hemolytic anemia, and leukocyte dysfunction.50
Risk
No consensus exists regarding risk stratification for adolescents and development of the refeeding syndrome. Recent literature suggests that, independent of the caloric approach to refeeding, RH is positively correlated with degree of malnutrition on admission, as measured by percent mBMI.10,15,54–56 In one study, researchers also found RH correlated with rate of weight loss before admission.10 On the basis of this information, the Society for Adolescent Health and Medicine directs hospitalists to be vigilant for RH in those inpatients presenting with severe malnourishment, as defined by %mBMI <70% or percent body weight loss of >20% in 1 year.5,50 Even when malnutrition at presentation is profound, initial laboratory evaluation is often within normal limits and should not give medical providers a false sense of security. Unremarkable laboratory profiles may reflect the body’s ability to promote hematologic homeostasis and may not correlate with the risk of developing the refeeding syndrome.49
Frequency of Evaluation
Frequency of serum laboratory evaluation for the prevention and identification of the refeeding syndrome is variable, and evidence-based monitoring strategies are lacking. Published protocols from major children’s hospitals typically recommend more frequent laboratory evaluation (basic metabolic panel, phosphorus, and magnesium at minimum) during the first week of hospitalization when risk of the refeeding syndrome is highest, allowing for clinical discretion thereafter.1,12,15,50 If hypophosphatemia or other abnormalities present, laboratories may be obtained more frequently (eg, from twice daily to every 4 to 6 hours).52 In a recent review of the incidence of refeeding laboratory abnormalities, researchers found that daily laboratory monitoring rarely altered medical management, and none of the resultant laboratory values changed the caloric refeeding plan, suggesting low use.57
Supplementation
Profound hypoglycemia may accompany early refeeding owing to depleted hepatic glycogen stores and the rapid influx of glucose into cells.58 Postprandial glucose checks may be warranted for young people who present with more severe malnutrition, although no evidence exists to definitively make this recommendation. Repletion of thiamine before refeeding remains controversial. The intracellular shift of glucose is thiamine-dependent, thus depleting already low stores observed during catabolism.59 Studies suggest administration of thiamine 100 to 300 mg/day for the first 3 days of medical refeeding is well-tolerated and may prevent the devastating sequelae of deficiency, as seen in Wernicke encephalopathy or congestive heart failure.47,58 The use of a daily multivitamin at onset of nutritional rehabilitation is also not yet delineated in the literature, although is likely to be of little harm. Several studies posit that prophylactic phosphate supplementation on admission may be a low-cost, low-risk intervention compared with daily laboratory monitoring, although more robust evidence is needed.12,17,49,50,57 Future studies should further elucidate risks and benefits of prophylactic electrolyte supplementation with careful attention to short- and long-term benefits in disease course as well as any potential adverse effects.
When medically possible, all supplementation should be provided orally because oral supplementation is associated with decreased length of stays and hospital costs and avoids the medical complications that can arise from IV infusion.60 If electrolyte values are borderline abnormal, emphasize the importance of ongoing nutritional rehabilitation and continue to use clinical judgment as to whether supplementation is warranted. Reference ranges for electrolytes vary by age and by institution, further complicating incidence rates of the refeeding syndrome and standardized repletion protocols.
Fluid Shifts
Monitoring for the presence of edema, particularly during the first few days of refeeding, is crucial to identifying early signs of the refeeding syndrome. Edema may be attributable to mild water retention from increased insulin secretion and thus sodium retention by the kidneys. Dependent edema may also result from low albumin, third spacing of fluid into the interstitium, or increased fragility of capillaries due to malnutrition.61 At its most severe, edema accompanied by pulmonary rales or elevated jugular venous pressure could imply true or impending cardiac failure.58 In future studies, researchers should investigate the prognostic use of edema as a marker of impending medical morbidity.
Fluid shifts and edema are best managed with frequent physical examination, elevation of the lower extremities, and strict monitoring of intake and output of fluids (urine output). Notably, edema is most common in those who have acutely stopped purging or those who were using laxatives or diuretics. Edema secondary to the abrupt cessation of purging behaviors is known as pseudo-Bartter’s syndrome and is distinct from the edema of the refeeding syndrome.61 This edema is a result of chronic dehydration with excessive aldosterone secretion. Management options include gentle IV hydration, potassium repletion when hypokalemic, and the transient use of low-dose spironolactone, an aldosterone antagonist.62
Family-Based Treatment
Family-based treatment (FBT) is an effective and evidence-based treatment of adolescent AN with promising short- and long-term outcomes in RCTs.44,63–67 FBT asks caregivers to assume primary responsibility for renourishment.68,69 Manualized FBT was designed for implementation on an outpatient basis; thus, initiation of this treatment is often deferred during inpatient medical stabilization.70 Adaptations to FBT, including inpatient adaptations, have revealed promising results across a multitude of settings, including acute medical hospitalizations.1,71,72 Whereas pediatric hospitalists will not be performing manualized FBT with families, the essential principles of this treatment can be woven into interactions with patients and families in preparation for the ongoing recovery process in outpatient treatment (See Table 2 and Fig 1 for examples).
Common Accelerant Approach to Medical Refeeding Protocols
. | Example Accelerant Approach . | Rationale . | Common Challenges and Solutions . |
---|---|---|---|
Weight gain goal | Safety has been demonstrated with 1 to 2 kg/wk.5 | Accelerates medical stability and transition to outpatient care | If there is a lack of appropriate weight gain or continued vital sign instability despite goal caloric intake, progress nutrition faster (eg, 400 kcal/d for 1–2 d). |
Caloric progression | Start at 2000 kcal/d and advance by 200 kcal daily21 | Safely brings medical benefit alongside decreased length of stay and hospitalization costs21 | Patient and family concerns about quantity of nutrition can be redirected by reassurance about safety and emphasis that food is the “prescribed medication” for current medical instability. |
Family involvement | Family is integrated early in the process and is empowered to help nourish the patient, even while medically hospitalized.1,16,43 | FBT is the gold standard for AN and AAN in young patients, and family involvement is crucial for best outcomes.44–46 | If the family is unable to engage or there is lack of buy in or frustration, implement psychoeducation, collaborative problem-solving, and a multidisciplinary team approach. |
Alternative feeding strategies | Focus on varied oral nutrition first, then by-mouth supplement, then alternative strategies like NG tube feedings1,16,20 | Alternative feeding options allow for rapid refeeding, even when oral intake alone is not possible. | If there is patient or family distress, framing any non–by-mouth options as part of a predefined protocol can help manage anxiety.26 |
. | Example Accelerant Approach . | Rationale . | Common Challenges and Solutions . |
---|---|---|---|
Weight gain goal | Safety has been demonstrated with 1 to 2 kg/wk.5 | Accelerates medical stability and transition to outpatient care | If there is a lack of appropriate weight gain or continued vital sign instability despite goal caloric intake, progress nutrition faster (eg, 400 kcal/d for 1–2 d). |
Caloric progression | Start at 2000 kcal/d and advance by 200 kcal daily21 | Safely brings medical benefit alongside decreased length of stay and hospitalization costs21 | Patient and family concerns about quantity of nutrition can be redirected by reassurance about safety and emphasis that food is the “prescribed medication” for current medical instability. |
Family involvement | Family is integrated early in the process and is empowered to help nourish the patient, even while medically hospitalized.1,16,43 | FBT is the gold standard for AN and AAN in young patients, and family involvement is crucial for best outcomes.44–46 | If the family is unable to engage or there is lack of buy in or frustration, implement psychoeducation, collaborative problem-solving, and a multidisciplinary team approach. |
Alternative feeding strategies | Focus on varied oral nutrition first, then by-mouth supplement, then alternative strategies like NG tube feedings1,16,20 | Alternative feeding options allow for rapid refeeding, even when oral intake alone is not possible. | If there is patient or family distress, framing any non–by-mouth options as part of a predefined protocol can help manage anxiety.26 |
Common Questions for the Hospitalist With Responses Using an FBT-Guided Framework
. | Hospitalist Response . |
---|---|
“What caused my child’s eating disorder?” | Eating disorders are complex, there is no one cause.69 |
Neither the young person nor the caregiver is responsible for the eating disorder.69 | |
“Is it serious?” | Engaging caregivers and patient in treatment is critical; this is often done in a “sincere but grave” manner, which stresses negative outcomes, medical comorbidities, and risk of mortality.43,69 |
Emphasizing the severity of illness purposely heightens anxiety and serves to increase engagement with treatment.43 | |
“Isn’t my child’s heart rate low because they are an athlete?” | Profound bradycardia is the body’s way of conserving energy in the face of acute starvation, mediated through increased vagal tone.76,77 |
This mechanism is distinct from bradycardia observed in athletes. | |
Bradycardia may be associated with other arrhythmias that can lead to sudden death.78 | |
“Why won’t my child just eat?” | Emphasize that the child is not their disorder; rather, the eating disorder has “taken over” the child and is influencing their thoughts and behaviors. |
Parents should know their child is not in control of the disorder. | |
The hospitalist can empower caregivers to act and speak against the disorder rather than the child. | |
“Why can’t my child see their weight?” | The number on the scale can heighten eating disorder cognitions and behaviors for patients; blinded weights may be preferable. |
Explicitly discussing daily weight values with the caregiver is pivotal because they need to feel engaged and responsible for further weight restoration on discharge. | |
“I understand my child needs to eat, but why aren’t we focusing on their mental health?” | Caregivers and patients will be eager to explore psychosocial factors that may have contributed to development of the disorder. It is important to emphasize that these issues will be addressed later in outpatient treatment, but, while in medical crisis, food is the focus.69 |
By preparing and empowering parents to take primary responsibility for weight restoration in the home, an important therapeutic objective has already begun in the hospital.43 | |
“What do we do when we are discharged?” | Clear expectations are given to the patient, family, PCP, school, dietician, and FBT therapist or team regarding the nature and frequency of follow-up before discharge (eg, weekly weight and vital sign checks, weekly FBT therapy, monthly meeting with dietician, excuse for gym, sports, and health class, and meal monitoring at school). |
Explain reasons the patient should re-present to the hospital (eg, weight stagnation or loss or medical instability). | |
Mobilize caregiver anxiety about discharge and eating disorder behaviors by empowering them to take responsibility for ongoing renourishment. |
. | Hospitalist Response . |
---|---|
“What caused my child’s eating disorder?” | Eating disorders are complex, there is no one cause.69 |
Neither the young person nor the caregiver is responsible for the eating disorder.69 | |
“Is it serious?” | Engaging caregivers and patient in treatment is critical; this is often done in a “sincere but grave” manner, which stresses negative outcomes, medical comorbidities, and risk of mortality.43,69 |
Emphasizing the severity of illness purposely heightens anxiety and serves to increase engagement with treatment.43 | |
“Isn’t my child’s heart rate low because they are an athlete?” | Profound bradycardia is the body’s way of conserving energy in the face of acute starvation, mediated through increased vagal tone.76,77 |
This mechanism is distinct from bradycardia observed in athletes. | |
Bradycardia may be associated with other arrhythmias that can lead to sudden death.78 | |
“Why won’t my child just eat?” | Emphasize that the child is not their disorder; rather, the eating disorder has “taken over” the child and is influencing their thoughts and behaviors. |
Parents should know their child is not in control of the disorder. | |
The hospitalist can empower caregivers to act and speak against the disorder rather than the child. | |
“Why can’t my child see their weight?” | The number on the scale can heighten eating disorder cognitions and behaviors for patients; blinded weights may be preferable. |
Explicitly discussing daily weight values with the caregiver is pivotal because they need to feel engaged and responsible for further weight restoration on discharge. | |
“I understand my child needs to eat, but why aren’t we focusing on their mental health?” | Caregivers and patients will be eager to explore psychosocial factors that may have contributed to development of the disorder. It is important to emphasize that these issues will be addressed later in outpatient treatment, but, while in medical crisis, food is the focus.69 |
By preparing and empowering parents to take primary responsibility for weight restoration in the home, an important therapeutic objective has already begun in the hospital.43 | |
“What do we do when we are discharged?” | Clear expectations are given to the patient, family, PCP, school, dietician, and FBT therapist or team regarding the nature and frequency of follow-up before discharge (eg, weekly weight and vital sign checks, weekly FBT therapy, monthly meeting with dietician, excuse for gym, sports, and health class, and meal monitoring at school). |
Explain reasons the patient should re-present to the hospital (eg, weight stagnation or loss or medical instability). | |
Mobilize caregiver anxiety about discharge and eating disorder behaviors by empowering them to take responsibility for ongoing renourishment. |
PCP, primary care physician.
Youth suffering from more severe AN and AAN tend to report greater benefit from FBT, thus providing a rationale for adapting FBT to higher levels of care, like the inpatient setting.73 Additionally, lack of cohesive messaging around the eating disorder between treatment providers and differing levels of care may ultimately undermine the effectiveness of FBT.74 Although there are many challenges inherent to adapting FBT to various care settings, a number of studies have revealed feasibility and efficacy as well as improved short-term medical and psychological outcomes.70,72,75 By understanding the key tenets of FBT and using them to inform common interactions with families and patients, the pediatric hospitalist can play a crucial role in accelerating treatment outcomes.
Conclusions
Emerging evidence should empower the hospitalist in more aggressive refeeding strategies without increased risk of the refeeding syndrome. Further research is warranted to clearly delineate the frequency and intensity of required monitoring for the refeeding syndrome and cardiac complications. The use of oral nutrition alone compared with incorporation of enteral refeeding should be focused on short- and long-term outcomes with respect to medical stability. The value of a graded approach to physical activity during the period of medical instability is an area of future research because evidence-based guidelines would maximize the benefits of activity while mitigating energy expenditure and risk of falls.
Pediatric hospitalists can be catalysts for positive outcomes in patients with restrictive eating disorders presenting for medical admissions. Adopting the nutritional, medical and therapeutic accelerants outlined above not only decreases length of hospitalization and associated costs but may also improve short- and long-term illness course. Furthermore, although no manual exists for implementation of FBT in the inpatient setting, the hospitalist’s words and framework have untold power to shape the trajectory of illness for young people embarking on a journey toward recovery.
FUNDING: No external funding.
Dr Downey conceptualized the narrative review and drafted the initial manuscript; Dr Brynes drafted the initial manuscript; and all authors reviewed and revised the manuscript and approved the final manuscript as submitted.
References
Competing Interests
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
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