A systematic review of enteral feeding by nasogastric tube in young people with eating disorders

Mitigating intubation stress, mucosa injury, and inflammatory response in nasogastric tube intubation via suppression of the NF-κB signaling pathway by engineering a hydration lubrication coating

Nasogastric tube (NGT) intubation is a common yet critical clinical procedure. However, complications arising from tube friction result in awful pain and morbidity. Here, we report a straightforward surface modification of slender NGT utilizing highly hydrated micelles that were composed of hyaluronic acid and Pluronic. The strong intermolecular hydrogen bonding facilitated the assembly of the micelles on NGT via a one-step dip coating process. The micelle coating conferred excellent hydrophilic, lubrication, anti-protein adhesive, and biocompatible properties. The in vivo efficacy of the micelle coating in alleviating catheterization irritation and mucosal injury was demonstrated using an NGT intubation model of rabbits. More importantly, compared to the paraffin oil coating (the current clinical means), the micelle coating possessed superior capability to reduce the inflammatory reaction caused by NGT intubation. The underlying mechanism was attributed to the suppression of the TLR4-IKBα-NF-κB inflammatory signaling pathway. This work provides a promising solution for developing lubricant medical coatings.

Enteral Tube Nutrition in Anorexia Nervosa and Atypical Anorexia Nervosa and Outcomes: A Systematic Scoping Review

Background: Anorexia nervosa and atypical anorexia nervosa require refeeding as a core part of their treatment, and enteral tube nutrition (ETN) may be needed in some individuals either to supplement or replace oral nutrition. This scoping review aimed to explore outcomes associated with phases of ETN, including initial nutrition, transition from enteral nutrition to oral intake, and to overall nutrition; Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews checklist was used. A systematic search was performed using the Ovid and the Web of Science databases, using relevant search terms identifying 37 studies to be included in the review. Quantitative and qualitative data were synthesised and presented; Results: ETN resulted in similar or higher weight gain than oral nutrition. Refeeding syndrome parameters were comparable between ETN and oral nutrition with some indication that prophylactic phosphate supported mitigation of hypophosphataemia. Global psychological parameters related to the eating disorder improved with nutrition; however, there was an indication that weight and shape concerns did not improve during this period. There was a lack of evidence related to transition from ETN to oral intake. Qualitative data indicated meanings attached to the tube, suggesting that additional support may be needed for the transition away from the tube. Furthermore, consideration may be required to support individuals in mitigating trauma related to ETN under restraint; Conclusions: ETN, when required, is a viable alternative to oral intake. Results indicated the need for further research, especially in the transition from ETN to oral intake with regard to strategies of transition and support, and outcomes related to these strategies.

Rates and risk factors of coercive measure use in inpatient child and adolescent mental health services: a systematic review and narrative synthesis

Reducing the use of coercive measures in inpatient child and adolescent mental health services (CAMHS) requires an understanding of current rates and associated factors. We conducted a systematic review of research published between Jan 1, 2010, and Jan 10, 2024, addressing rates and risk factors for mechanical, physical, or pharmacological restraint, seclusion, or forced tube feeding in inpatient CAMHS. We identified 30 studies (including 39 027 patients or admissions) with low risk of bias. Median prevalence was 17·5% for any coercive measure, 27·7% for any restraint, and 6·0% for seclusion. Younger age, male sex, ethnicity or race other than White, longer stay, and repeated admissions were frequently linked to coercive measure use. Variable rates and conflicting risk factors suggest that patient traits alone are unlikely to determine coercive measure use. More research, especially in the form of nationwide studies, is needed to elucidate the impact of care and staff factors. Finally, we propose reporting guidelines to improve comparisons over time and settings.

Treatment adherence and nasogastric tube use in hospitalized youth with anorexia nervosa and premorbid overweight/obesity

Youth with restrictive-eating disorders (EDs) often experience significant distress and difficulty with treatment adherence during nutritional rehabilitation. This study assessed whether youth with restrictive EDs and premorbid overweight/obesity admitted for inpatient nutritional rehabilitation experience greater psychological distress and difficulty with treatment adherence than youth with premorbid BMI <85th percentile. A retrospective chart review examined 150 youth hospitalized for medical complications of restrictive EDs. Rates of nasogastric tube (NGT; used when youth could not complete meals), agitation medication use, and disposition recommendation were compared across premorbid BMI groups. Patients with premorbid overweight/obesity were three times more likely to require NGT feeds. These findings suggest greater challenges with nutritional rehabilitation, specifically consuming nutrition orally, in patients with premorbid overweight/obesity, highlighting the need for early and individualized psychological support for this vulnerable patient population.

Nasogastric tube feeding under restraint: understanding the impact and improving care

BACKGROUND

Nasogastric tube feeding under physical restraint is an intervention that clinicians working in specialist mental health in-patient units may need to implement.

AIMS

To examine the impact of this intervention on people with lived experience, carers and staff.

METHOD

People with lived experience and parents and/or carers were recruited via UK eating disorder charity Beat. Clinicians were recruited via the British Eating Disorders Society's research forum. Qualitative semi-structured interviews were conducted and transcribed, and the results were thematically analysed.

RESULTS

Thirty-six participants took part, and overlapping themes were identified. All participants spoke in relation to four themes: (a) the short-term impact on the patient; (b) the impact on those around the patient; (c) the long-term impact; and (d) the positive impact. Subthemes were identified and explored.

CONCLUSION

This lifesaving intervention can also negatively affect patients, parents and carers, peers and staff. Further research is needed to understand how interactions and environmental modifications can mitigate the negative impacts.

Nasogastric Tube Feeding in Anorexia Nervosa: A Propensity Score-Matched Analysis on Clinical Efficacy and Treatment Satisfaction

The choice of a refeeding strategy is essential in the inpatient treatment of Anorexia Nervosa (AN). Oral nutrition is usually the first choice, but enteral nutrition through the use of a Nasogastric Tube (NGT) often becomes necessary in hospitalized patients. The literature provides mixed results on the efficacy of this method in weight gain, and there is a scarcity of studies researching its psychological correlates. This study aims to analyze the effectiveness of oral versus enteral refeeding strategies in inpatients with AN, focusing on Body Mass Index (BMI) increase and treatment satisfaction, alongside assessing personality traits. We analyzed data from 241 inpatients, comparing a group of treated vs. non-treated individuals, balancing confounding factors using propensity score matching, and applied regression analysis to matched groups. The findings indicate that enteral therapy significantly enhances BMI without impacting treatment satisfaction, accounting for the therapeutic alliance. Personality traits showed no significant differences between patients undergoing oral or enteral refeeding. The study highlights the clinical efficacy of enteral feeding in weight gain, supporting its use in severe AN cases when oral refeeding is inadequate without adversely affecting patient satisfaction or being influenced by personality traits.

Erythromycin Improves the Quality of Esophagogastroduodenoscopy in Upper Gastrointestinal Bleeding: A Network Meta-Analysis

BACKGROUND/AIM

Upper gastrointestinal bleeding (UGIB) usually requires esophagogastroduodenoscopy (EGD) for diagnostic and-potentially-therapeutic purposes. However, blood within the gastric lumen may hinder the procedure. Administration of prokinetics like erythromycin has shown efficacy. This network meta-analysis investigates the efficacy of this intervention prior to EGD.

METHODS

We performed a systematic literature search of Embase, PubMed/Medline, and other databases through March 8, 2022 to include randomized controlled trials (RCTs) comparing prokinetic use in EGD for UGIB. We used the DerSimonian-Laird approach to pool data and compare outcomes including need for repeat endoscopy and blood transfusion. Pooled prevalence of proportional outcomes, 95% confidence interval (CI), and p-values were calculated.

RESULTS

We included eight RCTs with four distinct intervention groups (erythromycin, placebo to erythromycin, nasogastric (NG) lavage and NG lavage + erythromycin) published between 2002 and 2020 with a total of 721 patients (mean age 60.0 ± 3.1 years; 73.2% male). The need for second look endoscopy was significantly lower with erythromycin than placebo (relative risk: 0.42, CI 0.22-0.83, p = 0.01). Using the frequentist approach, the combination of NG lavage and erythromycin (92.2) was rated highest, followed by erythromycin alone (73.1) for higher rates of empty stomach. Erythromycin was rated highest for lower need for packed red blood cell transfusion (72.8) as well as mean endoscopy duration (66.0).

CONCLUSION

Erythromycin improved visualization at EGD, reduced requirements for blood transfusion and repeat EGD, and shortened hospital stay. The combination of erythromycin and NG lavage showed reduced mortality.

Nasogastric tube feeding under restraint: practical guidance for children's nurses

The number of children and young people admitted to children's wards with an eating disorder has increased significantly since the start of the coronavirus disease 2019 (COVID-19) pandemic. In the most extreme cases, those with severe malnutrition may need to be fed via a nasogastric tube without their consent. Children's nurses working on hospital wards may therefore care for children and young people who need to receive nasogastric tube feeding under physical restraint. This article offers an overview of eating disorders and their detrimental effects as well as practical advice for children's nurses, supporting them to provide safe, compassionate and person-centred care to their patients.

The effect of oral refeeding compared with nasogastric refeeding on the quality of care for patients hospitalised with an eating disorder: A systematic review

AIM

The aim of this systematic review was to compare the benefits and harms of nasogastric and oral-based refeeding on the quality of care, including effectiveness, safety, and patient experience, for patients hospitalised with an eating disorder.

METHODS

A systematic search for studies measuring comparative data between nasogastric and oral refeeding methods was conducted in August 2021. Title and abstracts and remaining full texts were screened by both authors. Risk of bias was evaluated using the PEDro scale, and overall quality of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation narrative synthesis.

RESULTS

Seven studies (one randomised controlled trial, five non-randomised studies of interventions, and one qualitative study) with 917 participants were included. There was low certainty evidence that nasogastric refeeding resulted in no difference or a small increase in weekly weight gain, and moderate certainty of greater total weight gain, and very low certainty of increased length of stay compared to oral refeeding. There was no difference or a small increase in discharge weight and body mass index with nasogastric refeeding compared to oral refeeding. No serious adverse events were reported.

CONCLUSION

Patients selected for nasogastric refeeding have a longer duration of illness and lower admission weight, making it difficult to determine which refeeding approach is superior. However, the lack of clear difference in weekly weight gain and the lack of reported harms suggests that other factors such as the normalisation of eating behaviour may be taken into account when choosing the most appropriate refeeding method.

Early Naso-Gastric Feeding and Outcomes of Anorexia Nervosa Patients

Nutritional rehabilitation with weight restoration is an important step in patients hospitalised for anorexia nervosa (AN). Naso-gastric feeding (NGF) should be considered when oral nutrition (OF) and oral nutritional supplementation (ONS) are insufficient. We evaluated the role of NGF on short- and long-term outcomes, considering weight gain, the length of hospitalisation (LOS) and the time to relapse. We report on the characteristics of patients under 18 years of age with AN admitted to the Department of Emergency and Acceptance of the Bambino Gesù Children's Hospital, IRCCS, Rome, between March 2019 and August 2022. Three hundred and fifteen patients were enrolled. We compared patients treated with NGF (group A) and patients without NGF (group B). Group A was characterised by a significantly lower BMI on admission and discharge, more frequent use of inpatient psychotropic therapy (IPDT) and longer hospital stay. The time to relapse was significantly longer in group A compared to group B. An early NGF setting correlates with a longer time to relapse and may be associated with a shorter LOS. A high caloric intake with a balanced nutritional formula provided by NGF allows an earlier recovery. The main advantages of this approach could be the rapid discharge of patients and a more effective psychological and social recovery.

Ethical tensions in the treatment of youth with severe anorexia nervosa

Treatment of anorexia nervosa poses a moral quandary for clinicians, particularly in paediatrics. The challenges of appropriately individualising treatment while balancing prospective benefits against concomitant harms are best highlighted through exploration and discussion of the ethical issues. The purpose of this Viewpoint is to explore the ethical tensions in treating young patients (around ages 10-18 years) with severe anorexia nervosa who are not capable of making treatment-based decisions and describe how harm reduction can reasonably be applied. We propose the term AN-PLUS to refer to the subset of patients with a particularly concerning clinical presentation-poor quality of life, lack of treatment response, medically severe and unstable, and severe symptomatology-who might benefit from a harm reduction approach. From ethics literature, qualitative studies, and our clinical experience, we identify three core ethical themes in making treatment decisions for young people with AN-PLUS: capacity and autonomy, best interests, and person-centred care. Finally, we consider how a harm reduction approach can provide direction for developing a personalised treatment plan that retains a focus on best interests while attempting to mitigate the harms of involuntary treatment. We conclude with recommendations to operationalise a harm reduction approach in young people with AN-PLUS.

Management of anorexia nervosa in pregnancy: a systematic and state-of-the-art review

Anorexia nervosa is a potentially severe, chronic, and relapsing mental disorder that is more common in women and girls during the reproductive years (usually defined as those aged 12-51 years). It is associated with suicide and mortality linked with the physical consequences of starvation. Although anorexia nervosa is a disorder of low prevalence, and even lower prevalence in pregnancy, it is associated with substantial risks for the mother and infant when under-recognised and undermanaged. Despite the complexity and risk of managing anorexia nervosa in pregnancy, few studies are available to guide care. We conducted a systematic review, identifying only eight studies that addressed the management of anorexia nervosa in pregnancy. These studies were case studies or case reports examining narrow aspects of management. Subsequently, we conducted a state-of-the-art review across research in relevant disciplines and areas of expertise for managing anorexia nervosa in pregnancy and synthesised the findings into recommendations and principles for multidisciplinary management of anorexia nervosa in pregnancy. These recommendations included a focus on the specialist mental health, obstetric, medical, and nutritional care required to ensure optimal outcomes for women and their infants. Despite the complexity and risks, a gap exists in the comprehensive guidelines and recommendations for managing anorexia nervosa in pregnancy. This Review provides multidisciplinary recommendations for clinical care in this area. Managing anorexia nervosa in pregnancy is an area of clinical care that requires a multidisciplinary approach and includes those experienced in managing high-risk pregnancies.