NEDA TOOLKIT for Parents
Patients may experience abdominal pain and bloating
with meals from the delayed gastric emptying that
accompanies malnutrition. These symptoms may
respond to pro-motility agents [III]. Constipation may
be ameliorated with stool softeners; if unaddressed, it
can progress to obstipation and, rarely, to acute bowel
obstruction. When life-preserving nutrition must be provided to a
patient who refuses to eat, nasogastric feeding is
preferable to intravenous feeding [I]. When
nasogastric feeding is necessary, continuous feeding
(i.e., over 24 hours) may be better tolerated by patients
and less likely to result in metabolic abnormalities
than three to four bolus feedings a day [II]. In very
difficult situations, where patients physically resist and
constantly remove their nasogastric tubes, feeding
through surgically placed gastrostomy or jejunostomy
tubes may be an alternative to nasogastric feeding [II].
In determining whether to begin involuntary forced
feeding, the clinician should carefully think through
the clinical circumstances, family opinion, and
relevant legal and ethical dimensions of the patient’s
treatment [I]. The general principles to be followed in
making the decision are those directing good, humane
care; respecting the wishes of competent patients; and
intervening respectfully with patients whose judgment
is severely impaired by their psychiatric disorders
when such interventions are likely to have beneficial
results [I]. For cooperative patients, supplemental
overnight pediatric nasogastric tube feeding has been
used in some programs to facilitate weight gain [III].
With severely malnourished patients (particularly
those whose weight is <70% of their healthy body
weight) who undergo aggressive oral, nasogastric, or
parenteral refeeding, a serious refeeding syndrome
can occur. Initial assessments should include vital
signs and food and fluid intake and output, if
indicated, as well as monitoring for edema, rapid
weight gain (associated primarily with fluid overload),
congestive heart failure, and gastrointestinal
symptoms [I].
Patients’ serum levels of phosphorus, magnesium,
potassium, and calcium should be determined daily
for the first 5 days of refeeding and every other day for
several weeks thereafter, and electrocardiograms
should be performed as indicated [II]. For children and
adolescents who are severely malnourished (weight
<70% of healthy body weight), cardiac monitoring,
especially at night, may be desirable [II]. Phosphorus,
magnesium, and/or potassium supplementation
should be given when indicated [I].
b. Psychosocial Interventions
The goals of psychosocial interventions are to help
patients with anorexia nervosa 1) understand and
cooperate with their nutritional and physical
rehabilitation, 2) understand and change the
behaviors and dysfunctional attitudes related to their
eating disorder, 3) improve their interpersonal and
social functioning, and 4) address comorbid
psychopathology and psychological conflicts that
reinforce or maintain eating disorder behaviors.
i. Acute Anorexia Nervosa
During acute refeeding and while weight gain is
occurring, it is beneficial to provide anorexia nervosa
patients with individual psychotherapeutic
management that is psychodynamically informed and
provides empathic understanding, explanations, praise
for positive efforts, coaching, support, encouragement,
and other positive behavioral reinforcement [I].
Attempts to conduct formal psychotherapy with
starving patients who are often negativistic,
obsessional, or mildly cognitively impaired may be
ineffective [II].
For children and adolescents, the evidence indicates
that family treatment is the most effective
intervention [I]. In methods modeled after the
Maudsley approach, families become actively
involved, in a blame-free atmosphere, in helping
patients eat more and resist compulsive exercising
and purging.
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