Investigating two different refeeding formulations to improve safety and efficiency of hospital management of adolescent and young adults admitted with anorexia nervosa

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Patients admitted to hospital with anorexia nervosa (AN) require nutritional rehabilitation to reverse malnutrition and its complications. However, conservative guidelines advocate reintroducing nutrition at a very slow rate to avoid refeeding complications. At the Children’s Hospital Westmead and the Adolescent ward of Westmead Hospital, adolescents with AN have been successfully treated with more aggressive nutrition intervention without adverse side effects, and with a more rapid improvement of weight status. Evidence in higher caloric feeding is not as robust in the adult AN population as compared with adolescent patients. Of particular concern is the reintroduction of carbohydrate in a starved patient, which can lead to electrolyte derangement and increase the risk of developing refeeding complications. The standard enteral feed provided to patients provides 54% carbohydrate, while the literature suggests the use of continuous feeding strategies with less than 40% of energy from carbohydrate. The aim of this study is to test if a lower carbohydrate (CHO) content enteral feed will provide better health outcomes to adolescent and young adult patients with AN. This study will be multi-centred, including Westmead Hospital and RPAH. Patients admitted with AN and requiring enteral tube feeding (TF) during an 18 month data collection period, will be randomly assigned to receive either: 1. Standard treatment regime of nasogastric feeding (using an enteral feed with a carbohydrate content similar to standard care) commencing at 35mL/hr for 12 hours, providing 630kcal, 26g protein, 86g carbohydrate, 21g fat in 420mL feed, using a standard polymeric formula (Ensure Plus 54% CHO, 26% fat), and progressing to a rate up to 70mL/hr as tolerated; 2. Trial treatment regime of nasogastric feeding commencing at 35mL/hr for 12 hours, providing 630kcal, 26g protein, 45g carbohydrate, 39g fat in 420mL feed, using a lower carbohydrate, higher fat formula (Pulmocare 28% CHO, 56% fat), and progressing to a rate up to 70mL/hr as tolerated. Expected total number of patients, n = 48, with 24 in each arm. Inclusion and exclusion criteria will apply to participants. Primary outcome measure: Hypophosphataemia. Secondary outcome measures: Change in weight, Length of hospital stay (LOS), hypoglycaemia (nocturnal and postprandial), oedema, thiamine, electrolyte replacement, admission to ICU, days required to reach medical stability. This study has the potential to change practice in the nutritional management of young adults admitted with AN across the state, with the goal to inform future policy in this field. It will include the 2 hospitals in NSW with specialised inpatient treatment programs for adult patients with AN.