El documento resume los trastornos alimenticios de la anorexia y la bulimia en adolescentes. Describe la epidemiología, manifestaciones clínicas, criterios diagnósticos, comorbilidad psiquiátrica, pronóstico y guías de tratamiento para estos trastornos. También presenta un caso clínico de una adolescente con síntomas de anorexia y los criterios de admisión hospitalaria para estos trastornos.
1. Insuficiencia Nutricional en el
Adolescente: Anorexia y Bulimia
Dr. Moises Auron, FAAP, FACPDr. Moises Auron, FAAP, FACP
Staff, Departamento de Medicina Hospitalaria yStaff, Departamento de Medicina Hospitalaria y
Sección de Medicina Hospitalaria PediátricaSección de Medicina Hospitalaria Pediátrica
Nov – 26 – 2010
3. Objetivos
• Revisar
- Epidemiología y manifestaciones clínicas
- criterios diagnósticos de anorexia y bulimia
- criterios de admisión
- protocolos actuales de tratamiento
• Evitar el síndrome de “realimentación”
(refeeding)
• Apoyo multidisciplinario
4. Caso clínico
• Ana es una adolescente de 16 años que es evaluada
por amenorrea. Se documenta una pérdida ponderal
de 5 kg en 6 meses. Es estudiante modelo y está en
el equipo de atletismo de la escuela; corre 10 km
diarios y tiene una dieta muy restringida “ya que
quiere estar sana y no ser obesa”.
• EF: Peso 45 kg. Talla: 1.70m IMC 15.5
• Frecuencia cardiaca: 30x’ al dormir, 45x’ en decúbito
y 100x’ al estar de pié
• Presión arterial: 80/55 decúbito, 79/50 de pié
5. ¡Nadie se ha
comido mi
avena aún!
¡Esa Ricitos
de Oro me
tiene muy
preocupada!
7. Epidemiología
• Incremento desde 1950’s
• Anorexia nervosa: 0.5% de mujeres
adolescentes en EUA
• Bulimia nervosa: 1% - 5% en EUA
• Mujeres 10-20:1
- Hombres: 5% - 10% del total de casos
AAP Policy - Identifying and Treating Eating Disorders. Pediatrics 2003;111;204-
211.
Sim LA. Mayo Clin Proc. 2010;85(8):746-751
8. Factores de riesgo
• Historia familiar de trastornos de alimentación u obesidad
• Enfermedad afectiva y/o alcoholismo en familiares cercanos
• Ballet, gimnasia, modelaje, “deportes visuales”
• Rasgos de personalidad (perfeccionismo, rigidéz)
• Conducta alimentaria de los padres
• Abuso físico y sexual
• Baja autoestima
• Rechazo a la imágen corporal
• Historia excesiva de dietas y omisión de comidas
• Ejercicio compulsivo
Rome ES. Pediatrics 2003;111:e98 –e108.
9. Cambios Hormonales
• ↑ Ghrelina
• ↑ Péptido YY
• ↑ Colecistokinina
• ↓ Respuesta a Insulina
• ↓ Leptina
Prince AC. Am J Clin Nutr 2009;89:755–65.
10. Preguntas de Escrutinio
• Historial del peso corporal
- SCOFF (Sick, Control, Others, 14lb,
Food)
• Historial nutricional
• Historial de ejercicio
• Historia menstrual
Rome ES. Pediatrics 2003;111:e98 –e108.
Sim LA. Mayo Clin Proc. 2010;85(8):746-751
11. Conductas en los Trastornos de
la Alimentación
• Restrictiva
- reducción calórica marcada (~300-700 kcal/d)
- Ejercicio compulsivo
• Ingesta compulsiva y uso de catárticos
- Ingesta (“atracón”) de grandes cantidades
- Seguida de vómito auto-inducido
- Uso de laxantes
- Uso de diuréticos.
Yager J. N Engl J Med 2005;353(14):1481-8.
18. Triada de la mujer atleta adolescente
• Amenorrea
• Trastorno de la alimentación
• Osteoporosis u osteopenia
Greydanus DE. Pediatr Clin N Am. 2010; 57: 697–
718.
Birch K. BMJ. 2005; 330(29):244-46.
19. Anorexia: Criterios Diagnósticos
(DSM-IV-TR)
1. Miedo intenso a ganar peso o a convertirse en obeso, incluso estando por
debajo del peso normal.
2. Rechazo a mantener el peso corporal igual o por encima del valor mínimo
normal considerando la edad y la talla (peso < 85 % del esperable)
3. Alteración de la percepción del peso o la silueta corporales, exageración de su
importancia en la autoevaluación o negación del peligro que comporta el bajo
peso corporal.
4. Amenorrea ó ausencia de al menos tres ciclos menstruales consecutivos. (Se
considera que una mujer presenta amenorrea cuando sus menstruaciones
aparecen únicamente con tratamientos hormonales)
• Tipo restrictivo: no recurre a atracones ó purgas.
• Tipo compulsivo/purgativo: atracones alimentarios y purgas (auto-inducción del
vómito; uso de laxantes, diuréticos o enemas)
DSM-IV-TR. American Psychiatric Association. 2002.
Sim LA. Mayo Clin Proc. 2010;85(8):746-751
20. 1. Presencia de atracones recurrentes. Un atracón se caracteriza por:
a) ingesta de alimentos en un período breve (ej. 2 horas) en cantidad superior a la que la
mayoría de las personas ingerirían en las mismas circunstancias
b) sensación de pérdida de control sobre la ingesta del alimento
1. Conductas compensatorias inapropiadas, de manera recurrente con el fin de no ganar peso:
auto-inducción del vómito; uso de laxantes, diuréticos y enemas; ayuno y ejercicio excesivo.
2. Estos episodios ocurren en promedio, al menos 2/semana durante un período de 3 meses.
3. La autoevaluación está exageradamente influida por el peso y la silueta corporales.
4. La alteración no aparece exclusivamente en el transcurso de la anorexia nerviosa.
• Tipo restrictivo: ayuno o exceso de ejercicio
• Tipo compulsivo/purgativo: atracones alimentarios y purgas (auto-inducción del vómito; uso de
laxantes, diuréticos o enemas
Bulimia: Criterios Diagnósticos
(DSM-IV-TR)
DSM-IV-TR. American Psychiatric Association. 2002.
21. Trastorno alimenticio no
especificado: DSM-IV-TR
• Criterios de AN con presencia de menstruación
• Criterios de AN con peso normal
• Criterios de BN excepto atracones
• Peso normal con conductas maladaptativas (vómito
después de ingerir pequeñas cantidades)
• Paciente que mastica y escupe la comida sin deglutir.
• Atracones recurrentes sin otros criterios de BN.
DSM-IV-TR. American Psychiatric Association. 2002.
22. Diagnósticos diferenciales
• Neoplasia maligna
• Enfermedad inflamatoria intestinal,
enfermedad celíaca, malabsorción
• DM, hipertiroidismo, hipopituitarismo, Addison
• Enfermedad ó infección crónica
• Síndrome de la arteria mesentérica superior
AAP Policy - Identifying and Treating Eating Disorders. Pediatrics 2003;111;204-211.
Sigman GS. Pediatr Clin N Am. 2003; 50: 1139–1177.
23. Diagnósticos diferenciales
• Depresión mayor
• Trastorno afectivo
• Trastorno Obsesivo compulsivo
• Esquizofrenia
• Abuso de substancias
• Trastorno paranoide
• Trastorno de conducta
Fisher M. Pediatr. Rev. 2006;27:5-16
24. Comorbilidad Psiquiátrica
• Depresión mayor o distimia – 50-75%
• Trastornos de Ansiedad – 60%
• Trastorno Obsesivo-Compulsivo – 40%
• Abuso de Alcohol ó drogas – 12-27%
Yager J. N Engl J Med 2005;353(14):1481-8.
25. Curso de la enfermedad
ANOREXIA
• Mortalidad 5.6%
• Fluctuation ponderal frecuente
• Pobre pronóstico 10%–31%
• Tiempo de Recuperación ~ 6 años
• 50% desarrolla Bulimia
• ↑ depresión, ansiedad, alcoholismo
• 45% nunca se casan
BULIMIA
• Mortalidad 5.6%
• 50% se recuperan en 2 años
• Recaídas frecuentes
• 20%–46% trastornos de la
alimentación 6 años después
• 55% trastornos del ánimo
• 42% abuso de substancias
Rome ES. Pediatrics 2003;111:e98 –e108.
26. Factores Pronósticos
FAVORABLES
• Bulimia mejor que AN
• AN compulsiva mejor que
restrictiva
• Corta duración
• Mayor peso al alta
POBRE PRONÓSTICO
• Larga duración
• Bajo peso inicial
• ↑ Creatinina
• Obesidad pre-mórbida (BN)
• Ejercicio compulsivo
• Relación familiar conflictiva
Rome ES. Pediatrics 2003;111:e98 –e108.
27. Guías de manejo
Trastorno leve o temprano
• 85%–95% peso ideal, signos vitales estables
Trastorno establecido
• 75%–85% peso ideal. Cambios en signos vitales, laboratorios
anormales.
• Plan: 3 comidas y 3 colaciones –1500 kcal/d ↑ 500 kcal/ semana
- ↑ 0.5 – 1 kg por semana
• Psicoterapia y Dietista – comunicación cada 2 semanas
• Establecer contrato – tasa de ganancia ponderal, peso ideal,
consecuencias de falla.
• Visita cada 2 semanas documentar ganancia consistente de peso
mensualmente hasta que alcance el objetivo.
• Suplementos en caso de falla. Restringir actividad física.
Rome ES. Pediatrics 2003;111:e98 –e108.
Yager J. N Engl J Med 2005;353(14):1481-8.
36. Síndrome de refeeding: manejo
• Edema – elevación de las extremidades, uso
de medias elásticas
- Evitar diuréticos
• Distensión abdominal (gastroparesis)
metoclopramida
• Reflujo GE inhibidor de bomba de protones
• Importante seguimiento post-alta
Yager J. N Engl J Med 2005;353(14):1481-8.
37. • N = 36 AN restrictiva
• 60% cambios ortostáticos del pulso
• Cambios ortostáticos del pulso resueltos:
- Día 21 + 11
- 80% del peso ideal
J Adolesc Health. 2003; 32(1):73-77
38. • Estudio retrospectivo
• Comparación del QTc vs. sujetos normales
• Resultados:
- 45% de pacientes con AN QTc >440ms
- Factores predictores: bajo IMC, pérdida de peso rápida
• Aplicación
- ECG en todos los pacientes
- Reposo y monitoreo ECG
- QTc se normaliza con la rehabilitación nutricional
Acta Paediatr. 1999;88:304-9.
39. Anorexia: Evidencia limitada
• Insuficiente recomendación:
- Uso de antidepresivos
- Uso de antipsicóticos
- Tipo específico de terapia
• Individual vs. familiar
Claudino AM. Cochrane Database Syst Rev. 2006 Jan 25;(1):CD004365.
Court A. Eat Disord. 2008 May-Jun;16(3):217-23.
Fisher CA. Cochrane Database Syst Rev. 2010 Apr 14;(4):CD004780.
Hay P. Cochrane Database Syst Rev 2003;4:CD003909.
40. Bulimia: Evidencia mas sólida
• Terapia cognitivo conductual
- Tasa de remisión 30-40%
• Antidepresivos
- Efectivos en la etapa aguda por un
período breve
Bacaltchuk J. Cochrane Database Syst Rev 2003; 4: CD003391.
Shapiro JR. Int J Eat Disord 2007; 40: 321–36.
Treasure J. Lancet 2010; 375: 583–93
41. Protocolo Maudsley: La Familia
como bastión terapéutico
Lock J. Int J Eat Disord 2005; 37:S64–S67
Keel PK. Journal of Clinical Child & Adolescent Psychology, 2008;37(1):39–61.
Treasure J. Lancet 2010; 375: 583–93
• Premisa: Los pacientes con trastornos de la alimentación carecen de
capacidad para seleccionar adecuadamente alimentos que cubran sus
requerimientos nutricionales. Esto requiere un rol activo de los padres
en esta toma de decisiones.
• Fase 1 – Restauración del peso (Ocurre en la hospitalización)
- La familia selecciona los alimentos y estimula su ingesta.
- El cerebro del paciente está muy depletado como para tomar
decisiones.
• Fase 2 – El adolescente recupera el control sobre su ingesta (Externo)
• Fase 3 – Establecimiento de una identidad saludable (Externo)
42. Hospitalización
• Enfermería – debe proporcionar apoyo, pero ser firme
• Reiniciar dieta. (Padres eligen los alimentos – Maudsley)
• Completar dieta inacabada con suplementos nasogástricos
• Proveer calorias a través de 3 comidas y 3 colaciones.
• Iniciar 1200–1500 kcal/d e incrementar ~ 200 kcal/d hasta ganar
peso entonces 200 kcal/d cada 2–3 d hasta alcanzar el objetivo
de ingesta calórica.
• Monitorizar signos y síntomas del síndrome de realimentación,
arritmias, edema, etc.
• Monitorizar al paciente 24h para asegurar apego al tx.
- Al comer
- En el baño – prevenir accidentes por ortostatismo; evitar vómito,
uso de catárticos.
Rome ES. Pediatrics 2003;111:e98 –e108.
Attia E. N Engl J Med 2009;360:500-6.
43. Hospitalización
• Psicoterapia varias veces por semana – proveer apoyo
• Pobre capacidad de introspección del paciente
• Técnicas de relajación antes de ingerir los alimentos
• Duración de la admisión – suficiente para que el paciente
gane peso, normalize los signos vitales y laboratorios.
• Los pacientes readmitidos requiren un mayor peso para
poder ser dados de alta.
Rome ES. Pediatrics 2003;111:e98 –e108.
Attia E. N Engl J Med 2009;360:500-6.
45. Admisión
• Historia Clínica exhaustiva
• Examen del paciente desnudo en bata clínica
- Remover navajas, pastillas, etc.
- Remover efectos personales
• Explicar al paciente y su familia el plan de
tratamiento
- Expectativas claras del tratamiento
• Plan nutricional oficial empieza en la mañana
46. Paso diario de visita
• No mencionar:
- peso actual
- Calorías ingeridas
• Enfocar discusión en:
- Signos vitales
- Salud cerebral y cardiaca
• Establecer vínculo sólido de comunicación
con el paciente y el equipo.
47. Plan de tratamiento
• Explicar razonamiento clínico
- Apoyo nutricional, consultantes
- Reposo
- Privilegios en el hospital
- Compañía 24 horas al día
• Explicar rutina de enfermería
- Signos vitales
- Monitor cardiorespiratorio
48. Plan de tratamiento
COMIDAS
Deben de terminarse en 30 minutos
- incluye mantequilla, aderezos, jarabe, etc.
Si no se termina el 100% se dan suplementos nutricionales:
Desayuno: 0-50%: 2 Suplementos
50-90%: 1 Suplemento
Comida ó 0-50%: 3 Suplementos
Cena: 50-99%: 2 Suplementos
Si no se teminan oralmente en 20 min, se administran por SNG.
49. MENÚS: Maudsley vs. Intercambio
- Maudsley (<18 años)
- Intercambio (> 18 años)
Los menús son revisados y modificados acordemente
por el servicio de Nutriología para asegurar una
adecuada selección de alimentos que cubran los
requerimientos calóricos suficientes.
Plan de tratamiento
51. Enfermería
• Reposo absoluto
• No baño en regadera; usar cómodo
- Hasta la resolución de la ortostasis
• Usar bata clínica todo el tiempo
• Aplicar sonda NG de acuerdo a protocolo
• Asegurar compañía 24 horas
• Signos vitales por rutina.
52. Enfermería
• Privilegios:
- Admisión:
• Computadora, internet, TV, libros, visitas
- Privilegios adicionales:
• Celular (a las 24 hrs)
• Paseo en silla de ruedas, baño en regadera
sentado, visitas de amigos
- Remoción de privilegios
- Monitorizar el material, páginas de internet,
revistas (evitar retroalimentación negativa)
53. Enfermería
• Asegurar el uso de monitor cardiaco
• Cuantificación estricta de ingesta y excretas
• Peso diario a las 6 AM
- Paciente desnudo en bata clínica
- Después de orinar
- De espaldas a la báscula
- No informar al paciente del peso
54. Ordenes
• Dieta
- Regular Pediátrica
• 1500 kcal/d para mujeres
• 1750 kcal/d para hombres
• Incremento diario de 250 kcal/d
- Comunicación – Abordaje de rehabilitación nutricional:
• Maudsley < 18 yr
• Intercambio > 18yrs
- Notificar a Nutriología del apego al tratamiento
55. Ordenes
• Medicamentos
- Neutraphos (Fosfato de potasio)
• 2 paquetes v.o. dos veces al día x 5 días
mezclado con 240 ml jugo
- Lorazepam 0.5 – 1 mg prn 30 minutes antes de cada
comida
• Estudios de Laboratorio y gabinete
- Basales
• BH, QS, PFH, Mg, Phos, TSH, VSG, HCG, ECG
- Diariamente
• EGO en la mañana
57. Protocolo del acompañante
• Notificar a Enfermería de cualquier cambio
• Documentar cada 30 minutos
• Monitorizar tiempo de ingesta de alimentos
• Vigilar ingesta de alimentos y visitas al baño
• NO: Hablar, usar celular, ver TV, dejar al paciente solo
• NO: Tomar signos vitales
• NO: Discutir el peso con el paciente
• NO: Entablar amistad con el paciente.
58. Conclusiones
• Población compleja y llena de retos
• El protocolo es una guía
- Debe ser individualizado
• ¡Disfrutar el regreso de su personalidad
cuando recuperan su peso y nutrición!
Los trastornos de la alimentacion tienen una etiología multifactorial; son una causa importante de morbimortalidad en adolescentes y adultos jovenes.
Ocurre en mayor frecuencia en paises industrializados en donde hay un gran hincapie en la delgadez de la mujer como atributo de belleza.
Un hallazgo interesante ocurrió en las islas Fiji en donde no existía la anorexia hasta la década de los 90 en que hubo exposición a los programas de TV estadounidenses.
Background. Eating disorders in children and adolescents remain a serious cause of morbidity and mortality in children, adolescents, and young adults. The working knowledge of pathophysiology, recognition, and management of eating disorders continues to evolve as research in this field continues.
Reports of AN and BN are more common in industrialized nations where food is plentiful and where thinness for women is correlated with attractiveness. For example, the prevalence of AN in Greek girls living in Germany was double the rate for those girls living in Greece and Turkey where they remained less exposed to Western values equating thinness with beauty.
Behaviors simulating those seen in current eating disorders go back to the binging and purging seen in ancient Rome and the fasting and exercise reported among ascetics in the Middle Ages.
The term “anorexia nervosa” was used first in England in the 1880s to describe those who willfully decreased their eating and lost excessive weight; the term “anorexia hysteria” was used in France. Isolated cases were reported through the first half of the twentieth century, with a significant increase in cases beginning in the 1960s. This increase was noted principally among adolescents and young adults and has been considered an outgrowth of changing cultural norms in the ways that women’s shapes and sizes are viewed. Increases in economic and social choices available to women at that same time also may have played a role.
The term “bulimia” was introduced in 1979 to describe the binging and purging behaviors that were becoming more prominent in individuals who had eating disorders, some of whom were of normal weight or overweight. Those behaviors previously were considered simply to be a part of anorexia nervosa.
fascinating story of the Island of Fiji, which had no people who had eating disorders for 2 centuries until the appearance of American television programs in the mid-1990s, most exemplifies that change.
Ghrelin is a hormone produced mainly by P/D1 cells lining the fundus of the human stomach and epsilon cells of the pancreas that stimulates hunger.[1] Ghrelin levels increase before meals and decrease after meals. It is considered the counterpart of the hormone leptin, produced by adipose tissue, which induces satiation when present at higher levels. In some bariatric procedures, the level of ghrelin is reduced in patients, thus causing satiation before it would normally occur.
Leptin acts on receptors in the hypothalamus of the brain where it inhibits appetite
¿Cuánto te gustaría pesar?
¿Cómo te sientes con tu peso actual?
¿Alguien o tú tiene alguna preocupación sobre tus hábitos de ejercicio ó alimentación?
History of present illness
Weight history
-Maximum weight and when? Desired weight?
- How does the patient feel about his/her current weight?
- How frequently does she/he weigh him/herself?
- When did the patient begin to lose weight?
- What weight control methods have been tried?
Diet history
- Current dietary practices? Ask for specifics, amounts, food groups, fluids, restrictions.
- Any binges? Frequency, amount
- Any purging? Frequency, amount
- Abuse of diuretics, laxatives, diet pills, ipecac?
Exercise history: types, frequency, duration, intensity
Menstrual history: age at menarche? Regularity of cycles? Last normal menstrual period?
Review of systems
Dizziness, blackouts, weakness, fatigue
Pallor, easy bruising/bleeding
Cold intolerance
Hair loss, dry skin
Vomiting, diarrhea, constipation
Fullness, bloating, abdominal pain, epigastric burning
Muscle cramps, joint pains, palpations, chest pain
Menstrual irregularities
Symptoms of hyperthyroidism, diabetes, malignancy,
infection, inflammatory bowel disease
Psychological symptoms/history
Adjustment to pubertal development
Body image/self esteem
Anxiety, depression, obsessive-compulsive disorder,
comorbid
Past medical history
Family history: obesity, eating disorders, depression,
substance abuse/alcoholism
Social history: home, school, activities, substance use, sexual
history, sexual abuse
SCOFF is a brief instrument (5 questions, &lt;2 minutes to complete) that assesses the core psychopathology of AN and BN in early stages of the disorders. The SCOFF has been found to have high sensitivity and specificity for AN and BN.30,31 It includes the following questions: (1) Do you make yourself Sick because you feel uncomfortably full? (2) Do you worry you have lost Control over how much you eat? (3) Do you believe yourself to be fat when Others say you are too thin? (4) Have you recently lost more then Fourteen pounds in a 3-month period? and (5) Would you say that Food dominates your life? Although it has been suggested that 2 or more affirmative answers warrant further investigation for an eating disorder,
Medical Complications Resulting From Purging
1. Fluid and electrolyte imbalance; hypokalemia; hyponatremia; hypochloremic alkalosis.
2. Use of ipecac: irreversible myocardial damage and a diffuse myositis.
3. Chronic vomiting: esophagitis; dental erosions; Mallory-Weiss tears; rare esophageal or gastric rupture; rare aspiration pneumonia.
4. Use of laxatives: depletion of potassium bicarbonate, causing metabolic acidosis; increased blood urea nitrogen concentration and
predisposition to renal stones from dehydration; hyperuricemia; hypocalcemia; hypomagnesemia; chronic dehydration. With
laxative withdrawal, may get fluid retention (may gain up to 10 lb in 24 h).
5. Amenorrhea (can be seen in normal or overweight individuals with bulimia nervosa), menstrual irregularities, osteopenia.
with refeeding, 25% can get peripheral edema attributable to increased renal sensitivity to aldosterone and increased insulin secretion (affects renal tubules).
Vitamin deficiencies.
Bitot&apos;s spots are the buildup of keratin debris located superficially in the conjunctiva, which are oval, triangular or irregular in shape. These spots are a sign of vitamin A deficiency and are associated with conjunctival xerosis. In 1863 Bitot, a French physician, first described these spots.[1]
In ancient Egypt, this was treated with animal liver.
Emphasis on various weight categories Judo, Rowing, Taekwondo, Weight lifting, Wrestling
Emphasis on a prepubertal appearance Ballet, Figure skating, Gymnastics
Emphasis on a lean body Cross-country skiing, Long-distance running, Swimming
Emphasis on lean appearance Dance, Diving, Figure skating, Gymnastics, Synchronized swimming
In the younger age group, a diagnosis of anorexia nervosa can be established without any weight loss if the normal progression of weight and height has been delayed sufficiently. In addition, delayed menarche and primary amenorrhea may be signs of an eating disorder in this age group.
Although amenorrhea (ie, loss of 3 consecutive menstrual cycles) is currently required for the diagnosis, the importance of this symptom is unclear, and as such, the eating disorders workgroup of the Diagnostic and Statistical Manual of Mental Disorders (DSM) (Fifth Edition) has strongly considered removing it as a criterion for AN.6
Medical causes of weight loss
Decreased intake - Peptic ulcer ds., esophageal disease;
Malignancy
Chronic inflammatory disease
Impaired absorption - Small bowel disease;
Increased nutrient loss; Persistent diarrhea; Persistent vomiting; Diabetes mellitus
Excess energy demand Hyperthyroidism, Fever, Malignancy, Parasitic infections, Cholestasis or pancreatic insufficiency
El síndrome de realimentación es una entidad bien descrita, sin embargo, frecuentemente poco reconocida clínicamente.
Fué bien descrita en la segunda guerra mundial cuando se observó el desarrollo de falla cardiaca y edema periférico en prisioneros con desnutrición severa que recibieron restitución nutricional.
La hipofosfatemia es el estandarte del síndrome
Refeeding syndrome (RFS) is a term that describes the metabolic and clinical changes that occur on aggressive nutritional rehabilitation of a malnourished patient. It is a well described yet often underrecognized entity. Its recognition was heightened in the World War II era when prisoners who had undergone starvation developed cardiac failure and peripheral edema on nutritional replenishment.1 In Leningrad and The Netherlands, cases of cardiac insufficiency and edema were reported after refeeding survivors of the war who were starved because of scant food supplies.2 In 1944, Keys and colleagues deliberately starved and refed previously healthy men and observed cardiac decompensation in some patients who were orally fed.2,3 In the 1960s, the advent of parenteral nutrition (PN) allowed for a more aggressive means of nutritional rehabilitation. Reports of hypophosphatemic hyperalimentation syndrome soon followed in the 1970s. In 1980, Silvis and colleagues4 noted paresthesias, seizures, or coma in conjunction with hypophosphatemia in patients receiving PN. In the 1980s, Weinsier and Krumdieck5 wrote a critical paper that described cardiopulmonary complications resulting in the death of two chronically undernourished patients who received PN. Hypophosphatemia is the hallmark of RFS. Other electrolyte abnormalities are associated with RFS, however, such as hypokalemia and hypomagnesemia. Shifts in glucose, sodium, and fluid balance are also seen in RFS. Consequently, cardiovascular, pulmonary, neuromuscular, hematologic, and gastrointestinal complications occur. This syndrome can emerge with aggressive oral nutrition, enteral nutrition, or PN and can be fatal if not recognized and treated in a timely manner.
Existe una demanda incrementada en los producción de los intermediarios fosforilados de la glucólisis.
creating a high demand for the production of phosphorylated intermediates of glycolysis (ie, red blood cell adenosine triphosphate [ATP] and 2,3-diphosphoglycerate [DPG]) with inhibition of fat metabolism
Monitorizar:
Signos vitales
Monitorizar desarrollo de edema periférico
Monitorizar síntomas cardiopulmonares
There are several recommendations in initiating nutritional support. Regardless of the strategy, a gradual introduction of feeds is recommended. Proposed ranges for starting feeds include 25% to 75% of resting energy expenditure.2,3,6–8,10,13–15 In adults, reports recommend starting at 20 kcal/kg/d or 1000 kcal/d.2,8 In pediatric and adult patients, calorie intake is increased 10% to 25% per day or over 4 to 7 days until the calorie goal is met.10 Advancement of nutrition is based on biochemical stability. The saying ‘‘start low, and go slow’’ serves as a good guideline in approaching a malnourished patient. Protein is not restricted during nutritional support. Several studies show that high protein intake spares lean muscle mass and helps in its restoration.3 Sodium and fluids should be restricted during the initial period of refeeding to prevent fluid overload, especially in a patient at risk for RFS, whose cardiac function may be compromised. Palesty and Dudrick3 recommend restricting sodium to 20 mEq/d and total fluid to 1000 mL/d or less.
Patients with severe malnutrition, critical illness, severe trauma, and burns will also likely have a depletion of total body phosphorus (even if serum concentrations are normal), and their phosphate requirements will be higher.
0.08 mmol/kg if recent uncomplicated or mild hypophosphatemiaa - 2.3 to 2.7 mg/dL, moderate hypophosphatemia: 1.5 to 2.2 mg/dL.
0.16 mmol/kg if prolonged or severe hypophosphatemia - less than 1.5 mg/dL.
The management of refeeding complications is guided by clinical experience, in the absence of studies.
Is there any literature to support one refeeding approach in adolescents?
What are risk factors for and strategies to prevent refeeding syndrome and hypophosphatemia?
How common is orthostasis and when does it resolve?
How frequent is prolonged QTc syndrome and does it resolve?
Methods:
36 restricting pts admitted for nutritional rehab
Given 1500 kcals/day (+/- 400)
Admission stats: IBW 73.7%, HR 54, 60% orthostatic
Resolution of orthostasis = 48 hours of instability
Results:
HR changes persisted longer than BP
Mean resolution 21day +/- 11
Occurred when IBW = 80%
Applicability
Changes took time to evolve and take awhile to resolve
Counsel patients/ families accordingly
However,it concluded that psychotherapy (including psychoanalytic therapy, cognitive behavioral therapy emphasizing the correction of distorted thoughts and self-defeating behavior, or cognitive analytic therapy involving features of both) resulted in improved restoration of weight, return of menses among female patients, and improved psychosocial functioning, as compared with routine treatment, which generally involves education and emotional support.
The evidence base115 for the original CBT model of bulimia nervosa116 and its use as the first-line treatment is strong.
Although CBT has good acceptability, binge remission rates (cessation of binge eating or purging) at the end of treatments are only 30–40%.117,118
An enhanced form of CBT with a broader focus including interpersonal factors, emotional tolerance, perfectionism, and self-esteem did not substantially improve this outcome.119 Furthermore, combining antidepressants (tricyclics or fluoxetine) with CBT did not significantly add to the effect of CBT alone.117
Interpersonal therapy is efficacious as a treatment alternative, although it showed a slower response of symptom change than did CBT (similar results to CBT only after 1 year of follow-up).115,117 Other models of treatment are being considered for use in bulimia nervosa, such as those with a focus on emotional regulation (eg, dialectical behaviour therapy).120 Two studies have assessed the role of family-based psychotherapy for adolescent bulimia nervosa.121,122 One suggested that guided CBT could have advantages compared with family-based treatment in terms of cost and speed of response,121 whereas the other suggested that family-based treatment had advantages compared with individual supportive therapy.122 A 2004 review of treatment for bulimia nervosa and binging included seven trials in which participants with the form of eating disorder not otherwise specifi ed that was similar to bulimia nervosa formed part of the sample.123 The conclusion from this and from a recent trial119 is that CBT is as effective for non-specifi ed eating disorder similar to bulimia nervosa as it is for bulimia nervosa itself.
Pharmacotherapy has been recommended in the treatment of bulimia nervosa and binge eating disorder, especially if psychotherapy is either unavailable orunacceptable.82,83 Evidence from pharmacological trials in bulimia nervosa is strong, and it is increasing in studies of binge eating disorder, but this finding mainly indicates efficacy in the acute stage after short-term treatment.
Overall, evidence for long-term effects after medication is scarce. Additionally, pharmacological agents have been mainly tested in adults, and the results might not be generalized to adolescents and children. Moreover, use of antidepressant drugs in children and young people is controversial because of increased suicidal risk.124 Three systematic reviews detected strong evidence for the use of antidepressants to treat bulimia nervosa in the short term (around 8 weeks).115,117,125 However, the pooled effect from one meta-analysis (with eight studies, 901 patients) was judged only moderate for clinical improvement, which was defined as the number of patients with 50% or more reduction of binge eating (57% of patients receiving antidepressants vs. 33% receiving placebo), and remission rates with antidepressants and purging symptoms, but the safety profile of this drug still needs to be established in this disease.117,128,129
Minimizar uso de líquidos – usar comida sólida
RATIONALE FOR HOSPITALIZATION
Being underweight and poorly nourished is a severe health risk.
You have been hospitalized to address these serious concerns.
Some of these medical concerns may include low heart rate, abnormal blood pressure, unstable heart rhythms and electrolyte changes such as low potassium.
The goals of your hospitalization are to improve your nutritional status and these health problems.
These goals are attained by eating and drinking an adequate amount each day.
This program is standard for all patients with nutritional insufficiency.