title: A systematic review of approaches to refeeding in patients with anorexia nervosa.
abstract: OBJECTIVE
  Given the importance of weight restoration for recovery in patients with anorexia nervosa (AN), we examined approaches to refeeding in adolescents and adults across treatment settings.
  
  
  METHODS
  Systematic review of PubMed, PsycINFO, Scopus, and Clinical Trials databases (1960-2015) using terms refeeding, weight restoration, hypophosphatemia, anorexia nervosa, anorexia, and anorexic.
  
  
  RESULTS
  Of 948 screened abstracts, 27 met these inclusion criteria: participants had AN; reproducible refeeding approach; weight gain, hypophosphatemia or cognitive/behavioral outcomes. Twenty-six studies (96%) were observational/prospective or retrospective and performed in hospital. Twelve studies published since 2010 examined approaches starting with higher calories than currently recommended (≥1400 kcal/d). The evidence supports 8 conclusions: 1) In mildly and moderately malnourished patients, lower calorie refeeding is too conservative; 2) Both meal-based approaches or combined nasogastric+meals can administer higher calories; 3) Higher calorie refeeding has not been associated with increased risk for the refeeding syndrome under close medical monitoring with electrolyte correction; 4) In severely malnourished inpatients, there is insufficient evidence to change the current standard of care; 5) Parenteral nutrition is not recommended; 6) Nutrient compositions within recommended ranges are appropriate; 7) More research is needed in non-hospital settings; 8) The long-term impact of different approaches is unknown;
  
  
  CONCLUSIONS
  Findings support higher calorie approaches to refeeding in mildly and moderately malnourished patients under close medical monitoring, however the safety, long-term outcomes, and feasibility outside of hospital have not been established. Further research is also needed on refeeding approaches in severely malnourished patients, methods of delivery, nutrient compositions and treatment settings.
authors.affiliation: Department of Pediatrics, Division of Adolescent and Young Adult Medicine, University of California, San Francisco, Benioff Children's Hospital.
authors.forename: Andrea K
authors.initials: AK
authors.lastname: Garber
authors.affiliation: Director, Centre for Adolescent Health, Royal Children's Hospital; Geoff and Helen Handbury Chair of Adolescent Health, Department of Paediatrics, The University of Melbourne; and Researcher, Murdoch Childrens Research Institute.
authors.forename: Susan M
authors.initials: SM
authors.lastname: Sawyer
authors.affiliation: Department of Pediatrics, Division of Adolescent Medicine, Stanford University School of Medicine.
authors.forename: Neville H
authors.initials: NH
authors.lastname: Golden
authors.affiliation: Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine.
authors.forename: Angela S
authors.initials: AS
authors.lastname: Guarda
authors.affiliation: Department of Pediatrics, Division of Adolescent Medicine, Research Institute, Hospital for Sick Children, and University of Toronto School of Medicine.
authors.forename: Debra K
authors.initials: DK
authors.lastname: Katzman
authors.affiliation: Department of Adolescent Medicine, Sydney Children's Hospital Network, Westmead and the University of Sydney.
authors.forename: Michael R
authors.initials: MR
authors.lastname: Kohn
authors.affiliation: Department of Pediatrics, Division of Adolescent and Young Adult Medicine, University of California, San Francisco, Benioff Children's Hospital.|Department of Psychiatry, University of California, San Francisco.
authors.forename: Daniel
authors.initials: D
authors.lastname: Le Grange
authors.affiliation: Department of Psychological Medicine, Sydney Children's Hospital Network, The University of Sydney.
authors.forename: Sloane
authors.initials: S
authors.lastname: Madden
authors.affiliation: Director, Centre for Adolescent Health, Royal Children's Hospital; Geoff and Helen Handbury Chair of Adolescent Health, Department of Paediatrics, The University of Melbourne; and Researcher, Murdoch Childrens Research Institute.|Department of Nutrition and Food Services, The Royal Children's Hospital, Melbourne.
authors.forename: Melissa
authors.initials: M
authors.lastname: Whitelaw
authors.affiliation: Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine.
authors.forename: Graham W
authors.initials: GW
authors.lastname: Redgrave
mesh_terms: D000856:Anorexia Nervosa / Q000628:therapy*; D005260:Female; D006801:Humans; D008297:Male; D010288:Parenteral Nutrition / Q000379:methods*; D011446:Prospective Studies; D055677:Refeeding Syndrome / Q000150:complications; D012189:Retrospective Studies
keywords: anorexia nervosa; hypophosphatemia; length of stay; medical complications; medical stability; nutritional rehabilitation; refeeding; refeeding syndrome; weight restoration