From the Guidelines
The best time to initiate nasogastric (NG) feeding in an anorexic patient who is refusing oral intake is when they are anticipated to be unable to eat for more than seven days or if an inadequate food intake (less than 60% of estimated energy expenditure) is anticipated for more than 10 days. This recommendation is based on the ESPEN guidelines on enteral nutrition, which suggest that nutritional therapy should be started if undernutrition already exists or if it is anticipated that the patient will be unable to eat for an extended period 1.
When considering NG feeding for an anorexic patient, it's essential to assess their nutritional status and anticipated intake. According to the guidelines, if nutritional intake is chronically reduced, a corresponding weight loss and a concomitant worsening of prognosis are anticipated 1. A simple 24-hour recall can be used to demonstrate a reduced intake of normal food, and if this proves difficult, asking the patient about their nutritional intake compared to their usual intake before the onset of the disease can be helpful.
Key considerations for implementing NG feeding include:
- Starting with a low-calorie regimen to prevent refeeding syndrome
- Gradually increasing calories as tolerated
- Close monitoring of electrolytes, particularly phosphate, potassium, and magnesium
- Providing thiamine supplementation before initiating feeding
- Placing the NG tube by trained medical staff
- Using continuous rather than bolus feeding to reduce gastrointestinal discomfort
The decision to initiate NG feeding should be made by a multidisciplinary team, including psychiatrists, dietitians, and medical providers, and should balance the ethical obligation to prevent further physical deterioration while respecting patient autonomy when possible 1.
From the Research
Initiating Nasogastric (NG) Feeding in Anorexic Patients
The decision to initiate NG feeding in anorexic patients who are refusing oral intake is complex and requires careful consideration. The following points highlight the key aspects to consider:
- Timing of NG Feeding: There is no specific guideline on the best time to initiate NG feeding in anorexic patients. However, studies suggest that NG feeding can be initiated when the patient is refusing oral intake and is at risk of malnutrition or dehydration 2, 3.
- Assessment of Patient's Condition: Before initiating NG feeding, it is essential to assess the patient's condition, including their nutritional status, medical risks, and psychiatric outcomes 4, 5.
- Specialized Treatment: NG feeding should be initiated in a specialized unit with experienced healthcare professionals who can monitor the patient's condition and adjust the feeding regimen as needed 2, 6.
- Monitoring and Adjustments: Close monitoring of the patient's condition, including their weight, nutritional status, and medical risks, is crucial to ensure safe and effective NG feeding 3, 6.
- Potential Complications: NG feeding can be associated with complications, such as refeeding syndrome, hypophosphatemia, and tube manipulation. However, these complications can be minimized with careful monitoring and adjustments to the feeding regimen 2, 6.
Key Considerations
When initiating NG feeding in anorexic patients, the following key considerations should be taken into account:
- Individualized Care: Each patient's needs and circumstances should be assessed individually to determine the best approach to NG feeding 4, 5.
- Multidisciplinary Team: A multidisciplinary team, including healthcare professionals, dietitians, and psychiatrists, should be involved in the patient's care to ensure comprehensive management 2, 6.
- Patient's Autonomy: The patient's autonomy and wishes should be respected, and NG feeding should only be initiated when necessary and in the patient's best interests 3, 4.