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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. Page | 49