3.1 Prevalence and Epidemiology
In 13 studies in which NG was not the independent variable, the proportion of ED YP requiring NG feeding was between 6% - 66%.3, 7, 17, 22-26,31-33,38,42 Nehring and colleagues26 found that NG feeding was more likely to be required in: patients of a lower age at admission (14.3 compared to 15.3 years old, P<0.05), those with a shorter time period between disease onset and admission to hospital (P<0.0001), and longer time since last discharge (P<0.05). NG feeding is required more commonly in Early onset (EO) AN than adult onset (20% compared to 0%, P<0.05).3 Clausen13 described NG as the most frequently used involuntary measure in practice and is most commonly used in 15-17 year olds. Bayes and colleagues38 indicated that male requirements for NG is similar to that of females. According to Maginot and colleagues17 NG was more likely to be required in severely malnourished patients. O’Connor and colleagues42 found no correlation with high calorie initial feeding plans and increased risk of requiring NG feeding.
3.2 Patient and Staff Opinions on NG Feeding
5 studies used qualitative methods to analyse patient, parent and professional opinions on NG feeding.8,22,30,36,40 Hospital staff had greater levels of satisfaction when a joint care model between CAMHS and paediatrics was implemented for hospitalised YP with ED.22 Nursing assistants views centred around: NG being an unpleasant practice, becoming sensitized or desensitized, and the importance of developing coping mechanisms to manage the distress.36 Injuries were also described from head butting, hitting and abuse. 82% of Dietitians considered NG feeding a necessary procedure if oral diet is inadequate.8
YP viewed being NG fed as: an unpleasant experience, a necessary intervention, a psychological signifier of illness and a focus in a struggle for control by Halse and colleagues.36 Some described NG feeds as easier than eating as it “disguised” the amount due to no swallowing; others felt it was a form of punishment for not gaining enough weight. YP described manipulating the tube or syringing out the feed to prevent weight gain. Others found NG feeding a helpful motivator for oral intake.30 Nierderman and colleagues30 found 71% of YP in the study did not consent to being NG fed and 66% had to be restrained to NG feed, however later in their treatment many reflected that they understood the necessity of the procedure.
3.3 Feeding Regime and Calorie Intake
A variety of different feeding regimes were identified in this review which are summarised in Table 2. Refeeding protocols daily calorie intake varied greatly between studies particularly as many studies were evaluating the outcome of higher calorie refeeding protocols. 7,17,19,39,42 Most studies tailored the calorie requirements to the individual patient, accounting for initial weight for height percentage and signs of medical instability. They tended to start on daily intake of less than 2000kcal and increase periodically.
3.4 Nutritional Information
Only 3 studies reported nutritional information in the review. YP in the NG cohort in Maginot and colleagues 17 and Agostino and colleagues35 were supplied with a formulation containing 44% carbohydrate. In Paccagnella and colleagues37 all YP displaying signs of medical instability were commenced on solely NG feeding again using a formulation containing 44% carbohydrate with 19.7% protein and 36% lipids.
3.5 Length of Time on NG feeding / Weaning
Agostino and colleagues35 delivered nutrition solely via NG for 14 days before commencing oral diet in addition to NG feeding. The average length of time on NG feeding in this study was 20.7 days; NG was terminated as YP accepted more than 50% oral caloric quota compared to theoretical reported quota. Conversely to this, Akgul and colleagues24 stated that the average time YP required NG feeding was 2.5 days when treated on a paediatric ward.
Complications associated with NG feeding found in this review are summarised in Table 2, the most common being nasal irritation or epistaxis, anxiety related to the procedure and electrolyte disturbance (which occurred with both oral and NG refeeding). Overall, this review found 5 studies7,17,25,35,39 reported some incidence of electrolyte disturbance, 3 studies25,28,29 described epistaxis and 2 studies29,30 described behavioural problems associated with the procedure. No study reported a YP developed RS and Nehring and colleagues26 concluded that NG feeding had no impact on growth, recovery or presence of psychiatric co-morbidities.
3.7 Phosphate Supplementation
7 studies implemented supplementary oral phosphate either to reduce risk of hypophosphatemia or to treat it once detected to prevent the development of refeeding syndrome. This is summarised in Table 3.
3 studies20,22,24 reviewed NG treatment for YP in different settings. Fuller and colleagues20 demonstrated discrepancies in treatment provided to YP in different settings with specialist ED units being less likely to use pumps to deliver continuous feeds, tending to give bolus feeds of higher volume. Akgul and colleagues24 concluded the paediatric ward was a viable alternative for treatment (including NG) of YP with ED when specialist units are not available. In contrast Robb29 discovered that YP staying on a general hospital ward had a longer duration of admission in total than those on a specialist psychiatric ward.
3.9 Length of Stay
Hospital admission was significantly longer (P<0.0001) for YP requiring NG feeding compared to those managing an oral diet in Nehring and colleagues26 study. Conversely, Strik Lievers and colleagues33 highlighted that supplemental overnight NG feeding was associated with a shorter length of stay (LOS) than those consuming oral intake alone (36 days compared to 39.9 days). Agostino and colleagues35 supported this, demonstrating that YP consuming NG feeds had a mean LOS of 33.8 days compared to those having on an oral diet who had a mean of 50.9 days, however, the oral diet was lower in calories.
Strik Lievers and colleagues33 concluded that factors affecting LOS on a psychiatric inpatient ward included duration of AN, need for intensive care, adherence to oral intake, presence of a comorbidity, and requirement for NG feeding. In this study the mean LOS was 117 days for YP managing oral intake compared to 180 days for those requiring NG. Madden and colleagues19 indicated that a short admission with discharge upon medical stabilisation, compared to discharge on restoration of weight, resulted in no difference in readmission rates but reduced the LOS from 31.9 days to 21.7 days (P<0.05). From the studies in this review the length of admission varies from 19 to 180 days for YP with ED requiring NG.
3.10 Concurrent Therapy
5 studies17, 25,27,29,41 discussed therapy in adjunct to refeeding. In Madden and colleagues41 YP participated in family-based therapy (FBT) during their admission. Couturier and Mahmood 25 highlighted that meal support therapy reduced the requirement for NG feeding from 66.7% to 11.1%. In Robb and colleagues study29 YP were provided with meal support, planned group activities, daily group therapy, individual therapy, FBT three times per week, and expressive therapy twice per week. Gusella and colleagues31 compared parent led therapy (PLT) to non-specific therapy (psychologist led talking therapy). PLT was based on FBT and included parents reducing child exercise and increasing oral intake. Results demonstrated that YP receiving PLT had a significantly reduced requirement for NG (P<0.05). Maginot and colleagues17 concluded that YP requiring NG often required behavioural interventions in the acute refeeding phase to manage the refusal of oral intake.