657872

research-article2016
JAPXXX10.1177/1078390316657872Journal of the American Psychiatric Nurses AssociationKells and Kelly-Weeder

Literature Review
Journal of the American Psychiatric

Nasogastric Tube Feeding for

Nurses Association
2016, Vol. 22(6) 449­–468
© The Author(s) 2016
Individuals With Anorexia Nervosa: Reprints and permissions:
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An Integrative Review DOI: 10.1177/1078390316657872

jap.sagepub.com

Meredith Kells1 and Susan Kelly-Weeder2

Abstract
BACKGROUND: The use of nasogastric (NG) feeding in individuals with anorexia nervosa (AN) is endorsed
by national professional organizations; however, no guidelines currently exist. OBJECTIVES: The objectives
of this review were to identify and evaluate outcomes of NG feedings for individuals with AN and to develop
recommendations for future research, policy, and practice. DESIGN: An integrative review of the research literature
was conducted. RESULTS: Of the 19 studies reviewed, all indicated short-term weight gain following NG feeding.
Four studies examined adherence; nearly 30% of subjects were nonadherent as evidenced by tube manipulation. Seven
studies reported psychiatric outcomes, suggesting NG feeding reduces eating disorder behaviors but not overall
symptomology. CONCLUSIONS: NG feeding promotes short-term weight gain; however, long-term outcomes are
poorly understood. Future research, using rigorous methods, is still needed to inform practice.

Keywords
enteral feeding, nasogastric tube feeding, anorexia nervosa, eating disorders, malnutrition

Background required when severe malnutrition results in hemody-

Anorexia nervosa (AN) is a chronic, life-threatening psy-
chiatric illness characterized by a pathologic fear of
weight gain, excessive caloric restriction, and inability to
gain or maintain weight (American Psychiatric
Association [APA], 2013). The prevalence of AN is
reported to be between 0.3% and 1.7%, with increasing
incidence in all age groups and genders over the past cen-
tury (Hoek & van Hoeken, 2003; Smink, van Hoeken,
Oldehinkel, & Hoek, 2014). Mortality rates from AN
remain significantly high for up to two decades after ini-
tial treatment and are the highest among any psychiatric
illness (Papadopoulos, Ekbom, Brandt, & Ekselius,
2009). Recovery from AN becomes less likely with a lon-
ger duration of illness as measured by mental health
symptomatology, failure to gain weight, and maintain a
healthy weight for age and height (Von Holle et al., 2008).
Additionally, weight gain and eventual weight restoration
are central components in the treatment of individuals
diagnosed with AN (APA, 2006).
While many individuals with AN can be treated on an
outpatient basis with counseling, nutritional support, and
medical monitoring, inpatient medical and/or psychiatric
hospitalization may be necessary for individuals who
develop medical complications, or demonstrate acute
psychiatric concerns. Medical hospitalization is routinely
namic instability, end-organ damage, extreme weight
loss, and/or in cases of acute food refusal (American
Academy of Pediatrics [AAP], 2003; American Dietetic
Association [ADA], 2001; APA, 2006; Golden et al.,
2003). Goals of treatment, whether in medical or psychi-
atric hospital settings, include achieving weight gain
through nutritional intake, as weight gain reverses many
of the associated complications of malnutrition and is a
significant predictor of improvement in psychiatric out-
comes (Accurso, Ciao, Fitzsimmons-Craft, Lock, &
LeGrange, 2014). Cognitive impairments also have been
shown to be related to weight loss and improve with
weight restoration (Hatch et al., 2010).
To achieve weight gain, the ideal is for individuals to
consume nutrition orally. When this is not possible, short-
term nasogastric (NG) tube feedings may be required.
This practice has been endorsed by a number of
multidisciplinary and practice-based organizations (AAP,
1
Meredith Kells, MSN, RN, CPNP, Boston College, Chestnut Hill, MA,
USA; Boston Children’s Hospital, Boston MA, USA
2
Susan Kelly-Weeder, PhD, FNP-BC, FAANP, Boston College,
Chestnut Hill, MA, USA
Corresponding Author:
Meredith Kells, 140 Commonwealth Ave, Chestnut Hill, MA 02467.
Email: demaina@bc.edu
450 Journal of the American Psychiatric Nurses Association 22(6)
2003; ADA, 2001; APA, 2006; Golden et al., 2003). Two
of the most influential factors on oral intake for individu-
als with AN are comorbid psychiatric disorders and food
aversive behaviors. First and foremost, AN is a psychiat-
ric disorder with high rates of comorbid anxiety, obsessive-
compulsive disorder, and depression (Godart et al., 2003).
Individuals diagnosed with AN consistently report higher
levels of pre-meal anxiety when compared with other
groups (Buree, Papageorgis, & Hare, 1990; Leonard,
Pepina, Bond, & Treasure, 1998; Steinglass et al., 2010),
and food aversion is a frequently observed clinical find-
ing related to high levels of anxiety (Steinglass et al.,
2010). Food-related aversive behaviors, such as intake of
fewer overall calories, less dietary variety, and consump-
tion of foods that are perceived to be of lower caloric den-
sity, are implicated in poorer outcomes (Schebendach
et al., 2008) and have been suggested as a long-term con-
ditional response to internal fear of gaining weight
(Strober, 2004). Additionally, eating disorder–related
food behaviors are greatest when anxiety levels are high-
est (Lavendar et al., 2013). Therefore, higher levels of
comorbid psychiatric diagnoses are negatively correlated
with mealtime intake (Klein, Schebendach, Gershkovich,
Smith, & Walsh, 2010; Steinglass et al., 2010).
Although short-term NG feeding has been endorsed to
promote weight gain and to correct severe nutritional
deficiencies, the procedure is not without risk. Clinical
concerns associated with NG placement include tube dis-
placement, nasal cavity complications (septal abscess,
septal erosion, epistaxis, sinusitis), aspiration pneumonia,
perforation along gastrointestinal (GI) tract during place-
ment or indwelling, laryngeal edema, and otitis media
(Ismail et al., 2014).
Currently, there are no guidelines for specific clinical
situations in which NG feedings are warranted for patients
with AN. The importance of understanding the outcomes
related to NG tube feedings is critical and has implica-
tions for practice, policy, and future research. The results
of clinical studies examining these outcomes must be
evaluated in order to determine if NG feeding is a safe
and effective means of providing nutrition to individuals
diagnosed with AN. Outcomes of interest for individuals
diagnosed with AN who require NG feeding include
those that are physiologic, related to treatment adherence,
and psychiatric symptoms.
Physiologic outcomes of interest include anthropo-
metric measures such as weight and body mass index
(BMI), development of refeeding syndrome, and gastro-
intestinal distress. Weight is used as an indicator of treat-
ment progress in this population (APA, 2006) and has
implications in recovery and long-term outcomes (Von
Holle et al., 2008). In adult populations, BMI (weight in
kilograms divided by the square of height in meters;
Centers for Disease Control and Prevention, 2016) is
commonly used interchangeably with weight as an out-
come. In adolescent populations, percent median BMI
(current BMI divided by median BMI multiplied by 100)
is a more accurate measure of weight in due to the vary-
ing weight expectations associated with age and height
(Couturier & Lock, 2006).
Prevention of refeeding syndrome is a major consider-
ation for clinicians who treat severely malnourished indi-
viduals. This potentially fatal syndrome can occur during
nutritional rehabilitation when electrolytes shift from the
extracellular fluid into the intracellular space for energy
production (Kohn, Madden, & Clarke, 2011). This results
in depleted levels of electrolytes necessary for critical
homeostatic regulatory processes, such as cardiac con-
tractility and conductivity. Disequilibrium in these pro-
cesses may result in cardiac arrhythmias, pulmonary
edema, respiratory failure, rhabdomyolysis, seizures, and
death (Kohn et al., 2011; O’Connor & Goldin, 2011;
Tresley & Sheean, 2008). Hypophosphatemia, consid-
ered a hallmark of impending refeeding syndrome, is
used for clinical decision making with regard to caloric
prescription and electrolyte supplementation in individu-
als with AN (Kraft, Ptaiche, & Sacks, 2005; Skipper,
2012; Society for Adolescent Health and Medicine,
2014).
Gastrointestinal distress is another physiologic out-
come of interest. Many individuals diagnosed with AN
report GI symptomology both before and during the
nutritional rehabilitation. These symptoms may include
postmeal fullness, bloating, nausea, abdominal pain,
dyspepsia (Kuyumcu et al., 2013), higher levels of pre-
prandial fullness, and a decreased desire to eat (Leonard
et al., 1998; Stock et al., 2005; Sunday & Halmi, 1996).
While these symptoms do improve with weight restora-
tion (Kuyumcu et al., 2013), GI symptomology may pre-
vent individuals from consuming the calories required
for optimal nutritional restoration.
Fear of weight gain is a hallmark symptom for many
individuals with AN and is one of the diagnostic criteria
associated with this diagnosis. Given this underlying
pathology, individuals with AN may have difficulty
engaging in treatment protocols that promote weight gain
(Sly, Mountford, Morgan, & Lacey, 2014), making treat-
ment adherence an important outcome to consider when
evaluating the use of NG feeding in this population.
Specific adherence issues associated with NG feeding
protocols include patient manipulation or removal of the
NG tube as well as manipulation of the feeding equip-
ment (i.e., pump or apparatus).
Although weight gain is associated with an improve-
ment in psychiatric symptoms (Accurso et al., 2014), it is
important to consider the consequences of NG feedings
on individuals with AN. Halse et al. (2005) conducted a
qualitative study of 23 inpatient adolescents diagnosed
Kells and Kelly-Weeder 451

with AN to explore the meaning of NG feeding. The find-

ings suggest that a portion of the participants described
NG feeding as a positive, necessary experience, while
others felt that NG feeding was an indicator of their dis-
ease severity and an outward sign of illness. However,
many individuals described the need to regain strict con-
trol over their eating behavior, suggesting ongoing eating
disorder pathology. In considering the high rates of
comorbid anxiety and depression in this population
(Godart et al., 2003), and the negative effects these diag-
noses have on intake at meals (Klein et al., 2010;
Steinglass et al., 2010), it is important to evaluate the out-
comes of psychiatric variables. Psychiatric outcomes of
interest including distress caused by placement of or con-
tinuously indwelling NG tubes, as well as mental health
symptomology (anxiety, depression, eating disorder
pathology), must be explored when evaluating this treat-
ment modality.
A number of studies have examined the outcomes of
NG feeding in individuals diagnosed with AN. While
these studies contribute to the literature and enhance our
understanding of AN treatment outcomes, a comprehen-
sive review of the literature is not available and will be
required for protocol and policy development. Therefore,
the goal of this review was to (1) identify the physiologic,
patient adherence, and psychiatric outcomes of NG feed-
ings for individuals with AN; (2) evaluate those outcomes
within the context of risks and benefits; and (3) develop
recommendations for future research, policy, and
practice.

Method
This review utilized the Preferred Reporting Items for
Systematic Reviews and Meta-Analysis (PRISMA)
guidelines for reporting systematic reviews (Moher,
Liberati, Tetziaff, & Altman, 2009). In order to identify
relevant studies, an electronic database search of
PubMed, Embase, Cochrane, and CINAHL was per-
formed inclusive through May 2016, with no lower
limit on the year due to the paucity of research in the
Figure 1.  PRIMSA flow chart for identification and screening
topic area. The search strategy included the use of a of studies for review.
combination of terms including “anorexia nervosa,”
“enteral tube,” “nasogastric tube,” and “feeding.”
Ancestry searching was performed by examining the nature or did not include outcomes of NG feeding.
reference lists of relevant publications for additional Abstracts were reviewed for relevance and inclusion cri-
eligible articles. Data saturation was achieved when teria. Duplicates were removed. The remaining full text
further searching did not yield any additional, unique articles were assessed (see Figure 1).
studies. A quality assessment tool for quantitative studies
Data-based, published articles written in the English developed by the Effective Public Health Practice Project
language, which described physiologic, patient adher- was used to evaluate each article that met the inclusion
ence, and psychiatric outcomes of NG feeding in indi- criteria (Thomas, Ciliska, Dobbins, & Micucci, 2004).
viduals with AN were included in this review. Articles This tool was chosen because it provides a standardized
were excluded if they were anecdotal or editorial in assessment that can be used with diverse methodologies
452 Journal of the American Psychiatric Nurses Association 22(6)
to evaluate the quality of the quantitative studies and is
particularly useful when evaluating studies that describe
physiologic outcomes. This tool was used to score com-
ponents of selection bias, study design, confounders,
blinding, data collection methods, withdrawals and drop-
outs, as well as to assess intervention integrity and analy-
ses. According to established instructions, a final
composite score was tallied and rated on a scale of 1 =
strong, 2 = moderate, and 3 = weak overall.
Sample constellation, methodological features, and
results from each article were extracted (see Tables 1-4).
Using a constant comparison method, the data were ana-
lyzed for patterns and themes according to the method
described by Whittemore and Knafl (2005).
Results
A total of 19 studies met the inclusion criteria. Of those
evaluated, two (10.5%) were randomized controlled tri-
als, five (26%) cohort studies, one (5%) observational
prospective, four (21%) case reports, and seven (36%)
retrospective chart reviews, which included one retro-
spective observational, three retrospective cohort, and
three retrospective case/control studies. The mean com-
posite score as per the Effective Public Health Practice
Project quality assessment tool was 2.7. All studies
(100%) reported selected physiologic, four (22.2%)
reported patient adherence, and seven (36%) reported
psychiatric outcomes. The sample size ranged from 1 to
381 participants, and the mean sample size was 79. With
regard to gender, 10 studies (52%) were entirely female,
2 (10%) were entirely male, 6 (31%) were both male and
female, and 1 report did not detail gender breakdown for
study participants. Mean age was reported in 12 studies,
11 studies reported age ranges, 2 studies did not report
participant’s ages in any format, and 1 study reported age
at time of first admission but not specifically for when
NG feeding occurred (Nehring et al., 2014). For those
studies that reported age, the mean age of participants
was 21.35 years (range 11-57 years).
The majority of reports (52%) did not specifically dif-
ferentiate between psychiatry or medical settings, four
(21%) studies were conducted on an inpatient medical
unit, and four (21%) were conducted in an inpatient psy-
chiatric setting, one (5%) included ambulatory subjects
only. Ten studies (52%) compared NG and PO (oral feed-
ing) fed participants and eight (42%) examined only NG
fed participants. For those who received NG feeding, the
mean length of duration for NG feedings was 79.5 days
(range 1-599 days). Half of the studies reported on the use
of continuous NG feeding, one study used either over-
night or continuous feeding dependent on patient status,
one study utilized continuous then bolus feeds, three
studies described simultaneous PO and continuous NG
feeding, two studies reported the exclusive use of over-
night feedings, and two studies did not report the type of
NG feeding that was utilized.
Physiologic Outcomes
Body Mass Index and Weight Gain.  Fifteen (79%) studies
reported both weight and BMI, three (15%) studies
reported weight only, and one (5%) study reported BMI
only as outcome variables of NG feeding (see Table 3).
For studies that specifically investigated NG feeding
(without PO feeding comparison), participants were
reported to have a higher discharge BMI when compared
with BMI on admission (Gentile, 2012a, 2012b; Gentile
et al., 2013; Paccagnella et al., 2006; Shapiro et al., 2014).
When comparing participants who received NG feedings
to those who were orally fed, four studies reported higher
BMIs in individuals who received NG feedings (Gentile
et al., 2008; Rigaud et al., 2007; Robb et al., 2002; Silber
et al., 2004).
When investigating weight in kilograms as an out-
come measure, the results were similar to those reported
for BMI. Weight gain in those who received NG feedings
ranged from 5.7 to 15.9 kg over the duration of studies.
Weight gain was also demonstrated in studies examining
NG feeding alone (Bufano et al., 1990; Dalzell et al.,
1994; Gentile, 2012a, 2012b; Georges et al., 2004;
Paccagnella et al., 2006; Winston, 1987), as well as in
studies that compared NG with PO feedings, where par-
ticipants who received NG feedings were reported to
have gained more weight over the duration of the study
period than those who received PO feedings (Gentile
et al., 2008; Nardi et al., 2008; Rigaud et al., 2007; Robb
et al., 2002; Zuercher et al., 2003).
Rigaud et al. (2011) compared a cohort of adult outpa-
tients receiving only cognitive behavioral therapy (CBT),
a mainstay of psychological treatment in AN (Campbell
& Peebles, 2014; Murphy, Straebler, Cooper, & Fairburn,
2010), to a cohort receiving NG feeding in addition to
CBT. The results suggest that individuals who received
NG feedings in addition to CBT had significantly greater
BMI gain at 8 weeks (p < .02), 3 months (p < .02), and 6
months (p < .02) compared with before treatment. The
group receiving CBT alone had a significantly higher
BMI at 3 months and 6 months compared with before
treatment (p < .02). When comparing the two groups, sig-
nificantly greater BMI gains were noted in the NG group
compared with CBT group at 8 weeks and 3 months (p <
.05) as well as over their pretreatment weight at the
6-month follow-up visit (p < .05).
However, long-term weight gain results were incon-
sistent. In a retrospective chart review of adolescents and
young adults admitted to a medical children’s hospital,
Agostino et al. (2013) reported that although NG
 Table 1.  Sample Characteristics of Studies Examining Nasogastric Tube Outcomes for Individuals With Anorexia Nervosa.
Study Design Sample size (n) Diagnosis Age in years (M ± SD) Gender

Agostino, Erdstein, and DiMeglio (2013) Retrospective cohort analytic 165 Restrictive eating PO 14.9 ± 1.7 95% Female
disorders NG 14.9 ± 2.1
Bufano, Bellini, Cervellin, and Coscelli (1990) Cohort 9 AN Not reported 100% Female
Dalzell, Wilcox, Patrick, and Shepherd (1994) Case report 4 AN Median 14.15 (range 100% Female
14-16.1)
Gentile, Manna, Ciceri, and Rodeschini (2008) Observational retrospective cohort 99 AN 21.9 ± 8.6 95.9% Female
Gentile, Pastorelli, Ciceri, Manna, and Collimedaglia (2010) Cohort 33 AN 22.8 ± 7.6 100% Female
Gentile (2012a) Retrospective cohort 10 AN 22 ± 11.4 100% Female
Gentile (2012b) Retrospective cohort 122 AN 23.7 ± 9.7 96.7% Female
Gentile, Lessa, and Catteneo (2013) Case report 1 AN 24 100% Female
Georges, Thissen, and Lambert (2004) Case study 1 AN 35 100% Female
Nardi et al. (2008) Observational 61 AN-R 43 PO 23.5 ± 7.9 98.3% Female
AN-B/P 18 NG 27.2 ± 10.3
Nehring, Kewitz, von Kries, and Thyen (2014) Retrospective cohort 208 AN Age at time of NG 100% Female
feeding not reported
Paccagnella et al. (2006) Cohort 24 AN-R 19 18.5 ± 6.18 100% Female
AN-B/P 5
Rigaud Brondel, Poupard, Talonneau, and Brun (2007) Randomized control trial 81 AN-R 56 22.5 ± 4.5 97% Female
AN-B/P 25
Rigaud, Brayer, Roblot, Brindisi, and Verges (2011) Randomized control trial 103 AN 36 CBT 27.9 ± 6.2 100% Female
BN 67 NG + CBT 27.4 ± 8.1
Robb et al. (2002) Retrospective cohort analytic 100 AN PO 15.0 ± 1.8 100% Female
NG 14.8 ± 1.9
Silber et al. (2004) Retrospective cohort analytic 14 AN PO 14.9 ± 1.7 Not stated
NG + PO 13.8 ± 2.0
Shapiro, Davis, and Nguyen (2014) Case study 1 AN 20 100% Male
Winston (1987) Cohort 10 AN Not reported 90% female
Zuercher, Cumella, Woods, Eberly, and Carr (2003) Cohort analytic 381 AN-R 180 PO 25.2 ± 8.4 100% female
AN-B/P 201 NG 25.7 ± 9.6

Note. PO = oral feeding; CBT = cognitive behavioral therapy; NG = nasogastric feeding; AN-R = anorexia nervosa, restrictive subtype; AN-B/P = anorexia nervosa, binge/purge subtype; BN = bulimia nervosa.

453
454
Table 2.  Feeding Methods of Studies Examining Nasogastric Tube Outcomes for Individuals With Anorexia Nervosa.
Study Feeding methods

Agostino et al. PO: Daily calories divided into 3 meals and 3 snacks
(2013) Calories initially at 1,000 or 1,200 kcal/day, increased by 150 kcal/day to daily requirements
NG: All patients admitted to unit starting in May 2010
Continuous NG initially at 1,500 kcal/day or 1,800 kcal/day based on age
Calories increased by 200 kcal/day until max intake
Transition to PO bolus feeds over 3 days when HR > 45 at night × 2; achieved “maximal” calories, or completed 7 days NG
Bufano et al. Allowed to PO spontaneously for first 3 days of admission
(1990) Then gradual increase in NG feeding up to 14 hours per day
Started at 25% on Day 1 up to 100% of needs on Day 3
Caloric requirements calculated using Harris-Benedict equation
Individuals asked to be returned to PO feeding, treatment ended when PO > than basal metabolic rate × 3 days
Mean duration of NG feeds: 21 ± 14 days (range 9-51)
Dalzell et al. Continuous NG via pump × 24 hours per day, PO in addition to NG
(1994) Once 50% of lost weight regained, minimum 10 days of observed PO and then discharge
Median time of NG feeding 44 days
Gentile et al. Indirect calorimetry performed
(2008) Temporary NG feeding for “life-threatening situations”
Liquid caloric supplementation for severely malnourished individuals
Dieticians assist in menu selection for PO intake
Total duration of NG feeds: 4.4 ± 2.5 months until no longer “at risk for their lives” and “increasing oral food amounts”
Gentile et al. Body composition and resting energy expenditure calculated within 24-48 hours of admission
(2010) Those with “life-threatening situations,” immediate nutritional support at “lower rate” NG feeding started in 30 subjects started within 1-3 hours of admission via continuous
pump
Liquid oral supplements started in 3 subjects within 1-3 hours of admission
PO intake added when subjects agreed, gradually increased
Total duration of NG feeds: 60 days
Gentile Indirect calorimetry to establish caloric prescription
(2012a) In “life-threatening state,” NG at “low rate” via continuous pump started within 1-2 hours of admit
Calories from NG gradually decreased as oral diet increased
Length of NG feeding 90 days
Gentile Indirect calorimetry to establish caloric prescription
(2012b) For “severely malnourished” patients liquid food supplementation or NG feeding for “life-threatening situations”
Continuous NG infusion via pump until “no longer at life-risk” and “collaborate with treatment” and PO a “significant amount”
Length of NG for 20-30 days
Gentile et al. NG feeding × 24 hours/day using feeding pump
(2013) Initial caloric prescription determined by indirect calorimetry, repeated monthly
Calories increased to achieve weight gain
Fluid restriction 1,000 mL/day for 1 month, then 1,500 mL/day
PO feeding gradually added, PO only × 45 days prior to discharge
Length of NG feeding: 75 days

(continued)
 Table 2.  (continued)

Study Feeding methods

Georges et al. NG on day of admission, started at 500 mL (500 kcal) on Day 1, 750 mL on Day 2, 1,000 kcal on Day 3
(2004) On Day 3 introduced “free oral feeding”
Nardi et al. All patients initially PO, NG if oral refeeding failed (lack of weight gain of at least 1 kg in first week)
(2008) NG started slow and gradually increased rate via pump
PO in addition to NG feeding
Decreased NG as PO increased, stopped when showed weight gain, removed 2-3 days later
NG during daytime hours
Length of NG feeding 19.3 ± 13.1, median 18.5, range 7-39 days
Nehring et al. Nasogastric, details not specifically stated
(2014) 34% of sample received NG
Paccagnella Phase I: NG + IV on admission; Day 3-4 individuals instructed to PO “spontaneously”
et al. (2006) Phase II: Continuous NG + PO, NG discontinued when PO > 50% estimated caloric need using Harris-Benedict equation
Phase III: PO
Rigaud et al. NG: 3-5 days of IVF to correct electrolytes and dehydration, if necessary
(2007) Then 2 months of NG given via morning or afternoon hours, PO ad lib additional 1 week of PO prior to discharge
Length of NG: 2 months
Rigaud et al. Randomly assigned to either PO + CBT or NGT + CBT
(2011) NG group:
3 weeks only NG then introduced 1 PO meal at a time. NG volume adjusted according to PO intake
Resting energy expenditure calculated to gain 1.5-2.0 kg/month in AN patients
Total NG feeding duration: 2 months
Robb et al. PO: 3 meals and 2 snacks, gradual increase in kcal
(2002) NG: Overnight nasogastric feeding via pump with gradually increasing calories over 3 nights
PO feeding during the daytime in addition to NG feeds; ratio of daytime to nighttime feeds 2:1
NG stopped 3-4 days prior to discharge or achievement of 95% of ideal body weight
Silber et al. NG: Nocturnal NG protocol as well as PO protocol. NG protocol includes gradual increase in calories to prevent refeeding syndrome
(2004)
Shapiro et al. Started on 1,200 kcal/day diet via oral feedings supplemented by feedings via Dobb Hoff (NG) tube. Increased by 300 kcal every 2-4 days, goal of 2-3 lb weight gain per week.
(2014) Transitioned off of tube feeds after 10 weeks and 70% of ideal body weight. On discharge was eating 3,720 kcal/day.
Winston IV to correct electrolytes prior to NG
(1987) Continuous NG feedings via pump, PO ad lib additional and NG volume adjusted accordingly
Mean duration of therapy 21 days (range 14-42)
Zuercher et al. Voluntary nasogastric tube offered if low weight (<85% expected body weight) or if >85% expected body weight with food restriction of <500 kcal/day for 30 days prior to
(2003) admission, fluid restriction (not defined), or poor intake for 3 days prior to admission
NG feeds were always in conjunction with PO meals and snacks
NG discontinued at patient request, met weight expectations, before discharge to allow for PO intake
Mean duration of NG feeds 36 ± 21 days

Note. NG = nasogastric feeding; PO = oral feeding; CBT = cognitive behavioral therapy.

455
456
Table 3.  Physiologic and Treatment Adherence Outcomes of Nasogastric Tube Feeding in Anorexia Nervosa.
Refeeding syndrome–electrolyte abnormalities, Treatment
Study BMI (kg/m2), M ± SD Weight (kg) signs and symptoms GI distress adherence Length of stay

Agostino, Admit Rate of gain Hypokalemia More nausea Not reported PO 50.9 ± 24
et al. PO 16.7 ± 2.3 Days 1-7 (kg/week) 1 case each group (p = .005) NG 33.8
(2013) NG 16.6 ± 2.2 PO 0.8 Hypophosphatemia and (p = .002)
No discharge BMI data stated NG 1.22 PO abdominal
(p = .0001) 3 mild (0.87-0.80 mmol/L), 3 moderate (0.80-0.31 pain
Rate of weight gain mmol/L) (p = .009) in
Days 1-14 (kg/week) NG PO group
PO 0.69 No refeeding syndrome
NG 1.06
(p=0.004)
Initial weight loss
PO = 51%
NG group 6%
Met weight goals
PO = 32%
NG = 85%
Weight gain
PO 4.81 ± 2.3
NG 4.44 ± 2
(p = .41)
Bufano et al. Not reported Before NG: 34.51 ± 4.48 No significant changes in mean phosphorous, No nausea, 1 patient Not reported
(1990) After NG: 39.80 ± 3.30 potassium, magnesium levels before and after vomiting, quit after 2
(p = .001) NG treatment diarrhea, or weeks
Weight gain: 8.22 ± 3.43 kg/month 3 individuals with hypokalemia pretreatment abdominal
normalized posttreatment pain,
3 individuals with hypophosphatemia after 2 “some”
weeks of NG, 2 cases fell below 0.2 mmol/L constipation
Dalzell et al. Not reported Admit = 41.5 kg Not reported Not reported No tube Not reported
(1994) Discharge = 49.97 kg manipulation
All lost weight initial 2-3 days after
NG removal
Continued weight gain for 4-8 months
Gentile et al. Admit to discharge BMI Weight gain (kg): Not reported Not reported Not reported Length of stay overall
(2008) NG: 12.3 ± 0.9 to 18.4 ± 0.9 NG 15.9 ± 3.4 (months): 7.3 ± 4.5
PO: 12.8 ± 0.7 to 18.2 ± 0.8 PO PO 14.0 ± 2.3 Length of stay NG
Per month weight gain: (months): 7.3 ± 4.5
NG 2.8 ± 1.4 Length of stay PO
PO 3.4 ± 1.7 (months): 5.4 ± 3.9

(continued)
 Table 3.  (continued)

Refeeding syndrome–electrolyte abnormalities, Treatment

Study BMI (kg/m2), M ± SD Weight (kg) signs and symptoms GI distress adherence Length of stay

Gentile et al. Admit= 11.3 ± 0.75 Mean body weight increased from 35% hypophosphatemia on admission, 0% on days Not reported Not reported Not reported
(2010) DC= 13.5 ± 1 29.1 ± 3.2 kg to 34.5 ± 3.3 kg after 30 and 60
Mean BMI increased from 11.3 ± 60 days (p < .00001) Signs and symptoms of refeeding (heart failure,
0.7 kg/m2 to 13.5 ± 1 kg/m2 edema, rhabdomyolysis, and encephalopathy)
(p < .00001) not observed
Gentile Admit = 11.2 ± 0.7 Admit = 32 ± 3.8 No cases of refeeding syndrome reported Not reported Not reported Not reported
(2012a) DC = 17.3 ± 1.6 DC = 43.0 ± 5.7 No electrolyte derangements during treatment
No edema
Gentile Admit = 13.1 ± 1.6 Admit = 43.0 ± 5.5 Not reported Not reported Not reported Not reported
(2012b) DC = 16.4 ± 1.35 DC: 48.7 ± 4.4
Gentile et al. Admit = 9.6 Admit = 22.5 Not reported Not reported Not reported 120 days
(2013) DC = 44
Georges Admit = 10.3 Gained 6 kg during admission Hypophosphatemia to 0.8 mg/dL on day 4 from Not reported Not reported 1 month
et al. DC = Not stated 2.7 mg/dL (after 1.2 kg weight gain)
(2004) Improved over 5 days to 3.5 mg/dL with reduced
enteral intake to 750 kcal/day and supplemental
phos 1 g/day
Potassium range 3.3-4.0 reported, no hypokalemia
Nardi et al. PO: NG on average greater increase No refeeding syndrome Bloating 2 pulled tube PO: 19.5 ± 5.8
(2008) Admit = 13.8 ± 1.9; DC = 14.9 in weight and BMI during Leg edema: 10.5% NG; 4.8 % PO (not significant) and early 3 manipulated NG: 30.0 ± 10.1
± 1.6 hospitalization, p < .001 satiety: pump (range 15-45) days
NG: Neither PO nor NG was significant 42.1% NG; (p = .000)
Admit = 12.8 ± 1.7; DC = 14.2 predictors of weight gain at 35.7%
± 1.4 6-month follow-up PO (not
BMI at discharge and 6-month PO: significant)
follow-up comparable between Admit = 38.4 ± 5.9; DC = 40.6 ± 5.6
2 groups (p = .001)
NG:
Admit = 35.0 ± 7.5; DC = 38.8 ± 6.8
(p = .0002)

(continued)

457
458
Table 3.  (continued)
Refeeding syndrome–electrolyte abnormalities, Treatment
Study BMI (kg/m2), M ± SD Weight (kg) signs and symptoms GI distress adherence Length of stay

Nehring No association between NG and See BMI Not reported No Not reported Not reported
et al. growth association
(2014) between
NG and
persistence
or
remission
of AN at
follow-up
Paccagnella Admit=12.9 Admit= 33.0 kg 2 individuals with BMI < 11 kg/m2: on days 4-6 Significantly Not reported 20.7 ± 7.1 days
et al. 12-month follow-up: 17.3 12-month follow-up: 46.1 kg developed “minimal refeeding syndrome” improved
(2006) “Normalization” of weight in 6 (25%) Phosphorous (M ± SD) (p < .001):
subjects Phase I = 4.05 ± 0.14 abdominal
End phase II = 6.3 ± 0.1 (p = .03) pain,
Potassium (M ± SD) constipation,
Phase I = 4.0 ± 0.3 gastric
End phase II = 4.4 ± 0.1 (p = .8) motility,
retarded
gastric
exertion,
intestinal
distention,
precocious
satiety after
treatment
with NG
feeding
No nausea,
no vomiting,
diarrhea, or
worsening
abdominal
pain
reported
Rigaud et al. At 2 months: Weight gain at 2 months: No refeeding syndrome, no “severe” hypokalemia NG One quit NG 70 days
(2007) PO 15.9 (SD not reported); NG PO 5.9; NG 9.6 (p < .01) or hypophosphatemia 2 reflux after 12 days
17.9 ± 1.2 Met “normal” weight by DC: 5 constipation Average of
39% NG; 8% PO (p < .002) 1.9 tubes
placed over
2 months
(unclear
reasons)
(continued)
 Table 3.  (continued)
Refeeding syndrome–electrolyte abnormalities, Treatment
Study BMI (kg/m2), M ± SD Weight (kg) signs and symptoms GI distress adherence Length of stay

Rigaud, et al. Admit: NG = 18.2 ± 3.3; CBT = See BMI Hypokalemia significantly improved in NG Not reported 2 patients Not reported
(2011) 18.7 ± 3.1 compared to CBT groups at 8 weeks (p < .01), removed
For AN patients only: significantly improved compared to before tube
NG group with significantly treatment (p < .05)
higher BMI at 8 weeks,
3 months, and 6 months
compared to before treatment
(p < .02)
NG group with significantly
higher BMI at 8 weeks and 3
months compared to CBT
(p < .05)
CBT group significantly higher
BMI at 3 months and 6 months
compared to before treatment
(p < .02)
Robb et al. PO PO No refeeding syndrome Not reported 3 (5.8%) PO 22.1 ± 9.4; NG
(2002) Admit = 16.0 ± 1.8; DC = 16.8 Admit = 42.5 ± 7.6; DC = 44.8 ± 7.8 removed 22.3 ± 13.5
± 1.6 NG tubes and (p < .93) days
NG Admit = 41.1 ± 4.7; DC = 46.5 ± 5.1 required
Admit = 15.5 ± 1.7; DC = 17.5 Weight gain replacement
± 1.3 (p < .03) PO = 2.4 ± 1.8; NG = 5.4 ± 4.0
(p = .001)
Silber et al. PO PO No cases of refeeding syndrome Not reported Not reported PO =39.9 days
(2004) Admit = 17.4 ± 2.3; DC 18.5 DC = 49.1; Gain = 3.0 NG = 36.0 days
± 1.2 NG
NG DC = 53.7; Gain = 10.9 kg
Admit = 15.3 ± 1.7; DC = 19.1
± 3.7
Shapiro Admit = 11.59 Admit = 76.2 pounds No evidence of refeeding syndrome reported Not reported Not reported 106 days
et al. DC = 17.8 DC = 117 lbs
(2014)

(continued)

459
460
Table 3.  (continued)
Refeeding syndrome–electrolyte abnormalities, Treatment
Study BMI (kg/m2), M ± SD Weight (kg) signs and symptoms GI distress adherence Length of stay

Winston Not reported All individuals gained weight 30% ankle edema All 3 pulled tubes Not reported
(1987) Mean weight gain: 7.7 kg complained 2 disconnected
(range 4.5-15.2) of tube/poured
abdominal formula out
cramping of the bag/
and bloating manipulated
prior to pump
treatment—
improved
with PRN
antigas
medication
No acute
gastric
dilation
Zuercher, Admission Controlled for BMI, subtype of AN, Edema No Not reported Days:
et al. PO = 15.7 ± 1.7; NG = 14.2 daily kcal max, LOS, weight gain: 29 PO (13%); 29 NG (19%) (not significant) statistically PO 48.3 ± 19.4; NG
(2003) ± 1.7 PO = 5.7 kg; NG = 8.1 kg (p = .002) significant 60.8 ± 17.3
Weight gain per week differences When controlling for
PO = 0.82 kg; NG = 0.91 kg (p = .02) in diarrhea, severity of illness,
NG more than half their stay gained GERD no significant
most weight (p = .02) between difference
groups

Note. BMI = body mass index; CBT = cognitive behavioral therapy; DC = discharge; GERD = gastroesophageal reflux disease; NG = nasogastric feeding; PO = oral feeding.
 Table 4.  Psychiatric Outcomes of Nasogastric Tube Feeding in Anorexia Nervosa.
Tool or Psychological therapy
Author (year) instrument method Psychiatric outcomes reported Changes in eating behaviors

Nardi et al. None reported Not detailed No negative psychological implications of NG “majority of Increased oral intake over hospitalization
(2008) patients considered nasogastric feeding as a necessity to Six participants did not achieve adequate oral intake at discharge
overcome a critical situation” so received home NG feeding for 10-46 additional days
Nehring et al. SIAB-S Not detailed No difference in symptomology on Hopkins Symptom Not reported
(2014) Checklist or Structured Inventory for Anorexic and Bulimic
Eating Disorders (SIAB-S)-17 from baseline to follow-up
  Hopkins Symptom  
Checklist
Paccagnella SCL-90R Psychoeducational, Anxiety, interoceptive awareness affects treatment Oral intake increased over each phase of treatment
et al. (2006) EDI-2 psychodynamic, and willingness score (TWS) in Phase I (p < .05, p < .001,  
family approach respectively) Positive effect of NG feeding on ability of PO intake
Anxiety (p < .001), interpersonal distrust symptoms “High risk” patients accept NG feeding better than PO feeding
(p = .01), and obsessive compulsive symptoms (p < .05) in Phase I
affect TWS in Phase II, interpersonal distrust symptoms
affect TWS score in Phase III (p = .01)
No significant differences in pre- and posttreatment self-
report symptom inventory
Rigaud et al. None reported Not detailed No difference in NG vs. PO groups in fear of being fat, fear NG group significantly more cessation of binge/purge behaviors
(2007) of eating, anxiety, or depression scores (p < .01)
Rigaud et al. Binge Eating CBT Fear of gaining weight, food obsession, and eating during meal Significant difference in abstinence of binge/purge episodes in
(2011) Questionnaire persistent in both groups NG fed group compared with CBT alone at 8 days (p < .001)
developed for and 8 weeks (p < .01) and 1 year (p < .01) and abstinence of
study nonbinge vomiting at 8 days (p < .001)
  SF-36 Health Quality of life scores improved significantly more in NG fed No remission in nonbinge vomiting in CBT group (p < .03)
Survey for QOL compared with CBT alone (p < .01), specifically in physical
and mental health/well-being scores (p < .02)
  EDI BDI in NG fed improved significantly compared with CBT Significantly fewer binge/purge episodes in NG fed group
alone (p < .02) compared with CBT alone (p < .001)
  BDI Anxiety scores significantly improved in NG fed group  
(p < .001) and persisted × 12 months (p < .05);
improvement in anxiety subscores significantly greater in
NG fed group compared with CBT alone (p < .01)
  HAM-A Eating Disorder Inventory score overall improved in NG fed  
compared with CBT alone (p < .05)
  At 1 year, antidepressant drug dosages were more frequently  
lower than prior to treatment in NG fed group compared
with those receiving CBT alone (p = .06)
Shapiro et al. Not reported DBT, skills training, Cognitive processing, psychomotor activity, and affect Not reported
(2014) behavioral exposure and improved
response prevention, art
therapy, yoga therapy
Zuercher EDI Not detailed No significant difference in EDI scales from admission to Not reported
et al. (2003) discharge in NG fed vs. PO fed group

Note. BDI = Beck Depression Inventory; BMI = body mass index; CBT = cognitive behavioral therapy; EDI = Eating Disorder Inventory; HAM-A = Hamilton Anxiety Rating Scale; NG = nasogastric feeding; PO = oral feeding;
SCL-90R = Self-Report Symptom Inventory–Revised; SIAB-S = Structured Inventory for Anorexic and Bulimic Eating Disorders.

461
462 Journal of the American Psychiatric Nurses Association 22(6)
fed participants gained more weight in Days 1 to 14,
demonstrated less weight loss, and more frequently met
their weight goals than the PO fed cohort, there were no
differences in overall weight gain between the two groups
at the conclusion of inpatient hospitalization. Nardi et al.
(2008) conducted an observational study of medically
hospitalized adults in which participants initially received
PO feeding, and only received NG feedings if they failed
to gain 1 kg per week. The authors reported that 19 par-
ticipants (31%) required NG feeding; however, this
cohort gained more overall weight when compared with
the PO fed group (n =42; 69%), but neither NG nor PO
feedings were significant predictors of weight gain at
6-month follow-up. Nehring et al. (2014) collected retro-
spective medical data and prospective questionnaires on
208 individuals under the age of 18 years at time of hos-
pitalization. The authors reported that long-term BMI
outcomes were comparable for participants who were
exclusively PO fed and individuals who received NG
feedings at any time during their hospitalization.
Conducting a retrospective chart review, Zuercher et al.
(2003) reported that the duration of NG feedings during
residential psychiatric hospitalization was important in
achieving significant weight gain, as those who received
NG feedings for more than half of their hospital stay
gained the most weight (p = .02). Additionally, Shapiro
et al. (2014) present a case report of a 20-year-old male
who received 10 weeks of NG feeding during inpatient
hospitalization, only to be readmitted 2 months later with
a 19-pound weight loss. In summary, the majority of stud-
ies reported favorable increases in weight gain in hospi-
talized NG fed patients, those who received NG feedings
gained more weight than those who were PO fed; how-
ever, these results were not sustained over time.
Refeeding Syndrome and Serum Chemistry Values. Authors
who investigated the early signs of refeeding syndrome
reported varying results. One study of medically hospital-
ized participants who were initially exclusively NG fed
reported two cases of “minimal refeeding syndrome” in
patients with a BMI < 11 kg/m2, although the authors did
not describe how minimal refeeding syndrome was
defined (Paccagnella et al., 2006). The remainder of stud-
ies reported varying signs and symptoms of refeeding
syndrome, as detailed below, but no further cases of the
syndrome were identified.
When examining electrolyte abnormalities related to
refeeding syndrome, six studies (33%) reported resultant
hypophosphatemia and hypokalemia. Of the studies that
examined cohorts of only NG fed participants, Georges
et al. (2004) reported one case study of severe hypophos-
phatemia (phosphate level of 0.8 mg/dL) after a 1.2 kg
weight gain. Bufano et al. (1990) also described three
(33%) participants who developed of hypophosphatemia
2 weeks into treatment (2 cases below 0.2 mmol/L).
When comparing NG versus PO fed participants, few
authors reported information regarding serum chemistry
values related to refeeding syndrome; and of those that
did varying results were described. Agostino et al. (2013)
and Rigaud et al. (2007) reported no refeeding syndrome
for either NG or PO groups; however, Agostino et al.
(2013) did report six cases of refeeding hypophosphate-
mia in the PO group (three cases mild defined as serum
phosphorus level between .87 and .80 mmol/L; three
moderate defined as .80-.31 mmol/L), while no cases
were found in the NG fed group. Rigaud et al. (2011)
described significantly improved serum potassium in the
cohort receiving NG feedings at 8 weeks (p < .01) and
compared to before treatment (p < .05) compared to those
receiving CBT alone.
With regard to the development of peripheral edema
associated with refeeding syndrome, two studies reported
that 10.5% to 19% of NG fed participants versus 4.8% to
13% of PO fed participants (Nardi et al., 2008; Zuercher
et al., 2003) demonstrated edema, while Winston (1987)
reported that 30% of the cohort who were exclusively NG
fed developed peripheral edema. Overall, 61% of the
studies detailed some aspect of refeeding syndrome sign
or symptom development and of these findings the rates
of ankle edema were high and the rates of electrolyte dis-
turbance were low.
Gastrointestinal Symptomatology.  Symptoms of GI distress
including nausea, abdominal pain, bloating, constipation,
and satiety/fullness were reported by 6 of the 19 (31%)
studies reviewed; however, the findings varied widely in
terms of which symptoms were reported as well as which
feeding approach was employed. Agostino et al. (2013)
reported nonsignificant increased rates of nausea and
abdominal pain in the NG fed group versus the PO fed
group. Nardi et al. (2008) described nonsignificant
increased rates of bloating and early satiety in the NG
cohort, while Zuercher et al. (2003) found nonsignificant
increased rates of gastroesophageal reflux and osmotic
diarrhea in the PO fed cohort.
For studies that included exclusively NG fed patients,
Winston (1987) reported that all participants complained
of cramping and bloating prior to treatment and mild
bloating persisted in 30% of the study participants after
nutritional rehabilitation; however, all bloating symptoms
were resolved with as-needed medication. In contrast,
Paccagnella et al. (2006) reported that patients had signifi-
cant (p < .001) improvements in abdominal pain, consti-
pation, gastric motility, retarded gastric exertion, intestinal
distention, and precocious satiety at completion of NG
feeding when compared with pretreatment levels.
Additionally, Bufano et al. (1990) reported no GI side
effects including vomiting, nausea, diarrhea, or abdominal
Kells and Kelly-Weeder 463
pain. Overall, the studies reported conflicting results
regarding which cohort of patients (NG vs. PO fed) expe-
rienced greater GI disturbance during the nutritional reha-
bilitation process.
NG Treatment Adherence
Four studies (22%) reported adherence outcomes and
included measurements related to participants removing
the NG tube or manipulating the tube or feeding pump in
an attempt to decrease intake (Nardi et al., 2008; Rigaud
et al., 2011; Robb et al., 2002; Winston, 1987). Two to
five (1.9% to 30%) participants per study removed their
tube against medical advice and two to three participants
per study were reported to have manipulated either the
NG tube or feeding pump (Nardi et al., 2008; Rigaud
et al., 2011; Robb et al., 2002; Winston, 1987). Rigaud
et al. (2007) reported that participants required an aver-
age of 1.9 (range 1-8) tubes placed due to manipulation
over the 2-month study period.
Psychiatric Outcomes
While most studies focused on physiologic outcomes, six
reports (31%) examined psychiatric outcomes in addition
to the physiologic variables described above (see Table 4).
Overall, these outcomes reflected wide variations in lev-
els of improvement in psychiatric symptomatology fol-
lowing NG feedings. A study by Rigaud et al. (2011)
suggested that those who received NG feeding in con-
junction with CBT were more quickly and more fre-
quently abstinent from binge/purge behaviors (p < .001).
Rigaud et al. (2007) reported that there were no differ-
ences in anxiety and depression scores between those
receiving NG and PO feedings; however, in a later study
Rigaud et al. (2011) suggest that individuals who received
NG feedings for the first 2 months of treatment had
greater improvements in quality of life (p < .01), anxiety
(p < .01), and depression (p < .001) than those partici-
pants who received psychotherapy with CBT alone.
However, both Rigaud et al. (2007) and Rigaud et al.
(2011) detail that food and weight symptomatology (fear
of gaining weight, obsession with food, fear of eating
during meals) did not significantly improve in either the
NG or PO fed cohorts.
When investigating ED symptomology using the
Eating Disorder Inventory (EDI), Rigaud et al. (2011)
reported improvement in EDI scores in the NG group as
compared with the group who received CBT alone (p <
.05); however, Zuercher et al. (2003) reported that there
was no significant improvement in EDI scores in either
NG or PO fed groups. Paccagnella et al. (2006) and
Nehring et al. (2014) likewise found that there were no
significant changes in self-reported symptomatology in
PO versus NG fed cohorts (Nehring et al., 2014) or after
nutritional rehabilitation using both PO and NG feeding
(Paccagnella et al., 2006). Overall, the studies suggest
that although NG feeding may not influence eating disor-
der symptomology as measured by eating disorder scales
or reports of food and weight-related obsessions, the
treatment modality may decrease some eating disordered
behaviors, specifically binge/purge behaviors and comor-
bidities such as anxiety and depression.
Discussion
Nutritional rehabilitation and restoration of weight is of
critical importance to the treatment plan for individuals
diagnosed with AN in order to reverse the medical com-
plications of malnutrition, improve psychiatric outcomes
(Accurso et al., 2014), and increase the likelihood of
long-term recovery (Von Holle et al., 2008). However,
due to the pathological fear of weight gain (APA, 2013),
associated food-related compulsions (Schebendach et al.,
2008), and high rates of comorbid anxiety (Godart et al.,
2003), oral intake of nutrition for individuals with AN
can be challenging. In order to accomplish life-sustaining
weight gain, enteral nutrition may be necessary (Golden
et al., 2003).
The literature detailed in this review represents a vari-
ety of NG feeding options (bolus vs. continuous feeding,
NG feeding alone vs. supplemental to PO feeding), which
may be incorporated into the treatment plan of individu-
als with AN. Rationale for choice in feeding methods
may be related to individual provider preferences, admis-
sion criteria, institutional procedures and protocols, reim-
bursement restrictions, and others. However, this limited
review may also be highlighting the relative paucity of
research on the utility, safety, and efficacy of NG feeding
and the subsequent lack of global consensus on the spe-
cifics of the method. Additionally, the conditions under
which NG feeding is necessary or effective remain
unclear. Some have proposed “persistent” failure of
weight gain, life-threatening situations, and psychologi-
cal worsening as potential criteria for implementation of
the treatment modality (Mehler, Winkelman, Andersen,
& Gaudiani, 2010). However, clear guidelines or opera-
tional definitions of these criteria continue to be needed.
The leading discipline-specific organizations support the
use of NG feeding in individuals with AN, recommending
short-term use of the modality and citing a lack of evidence
to support long-term use (APA, 2006; Golden et al., 2003).
However, based on the results of this review, it remains
unclear what “short-term” versus “long-term” feeding indi-
cates as the studies included in this review report NG feed-
ing durations of 7 days to over 4 months. All the studies
reported relative weight gain in the cohort receiving NG
feeds; however, without comparable durations of treatment
464 Journal of the American Psychiatric Nurses Association 22(6)
and longitudinal data, it is impossible to state if short- ver-
sus long-term NG feeding demonstrated significantly dif-
ferent changes in weight. Given the lack of consistency in
variables measured in each study, it is difficult to determine
if short- versus long-term NG feeding demonstrated signifi-
cant differences in outcomes.
In the current health care environment, length of stay,
resource allocation, and cost of care are of utmost impor-
tance. In the reviewed studies, length of stay was related
to the length of the NG feeding regimen and ranged from
weeks to months of treatment. Long-term outcomes were
only discussed in three studies (Dalzell et al., 1994;
Rigaud et al., 2011; Shapiro et al., 2014), making it dif-
ficult to determine best practice regarding length of NG
feeding duration. Despite the relatively long inpatient
hospitalizations of up to 7 months described in this
review, none of the studies examined rehospitalization
rates, and only one reported that there was no association
between method of refeeding (NG or PO feeds) and
remission for AN (Nehring et al., 2014).
It is noteworthy that, although AN is a psychiatric ill-
ness, only 31% of the studies examined reported on psy-
chiatric outcomes. These results begin to explore the
important considerations of the effects of NG feeding on
mental health; however, the relatively limited number of
studies reporting psychiatric outcomes and the varied
results provide little guidance on the application of this
treatment modality. Previous literature has highlighted
that weight restoration improves psychiatric symptoms
for individuals with AN (Accurso et al., 2014). Although
the results from the reports detailed in this review suggest
that NG feeding may improve ED-specific behaviors
(binge/purge behaviors; Rigaud et al., 2007; Rigaud et al.,
2011), there was no improvement found in overall ED
symptomatology and it is unclear how other interven-
tions, such as therapy provided during hospitalization,
contributed to those findings. Future research needs to
further investigate the association between NG feeding
and psychiatric symptomatology.
It may be important to consider the implications of
weight restoration on the cognitive abilities of the indi-
vidual and subsequent uptake of psychological treatment.
In a meta-analysis Zakzanis, Campbell, and Polsinelli
(2010) describe that as weight in BMI decreases, cogni-
tive impairment of the individual with AN increases. In
the study by Rigaud et al. (2011), those who received NG
in addition to CBT showed significantly greater BMI
gains at 8 weeks and 3 months. As cognitive functioning
has been suggested as a mechanism to the maintenance of
eating disorders, the effect of those receiving CBT alone
may be muted due to malnutrition influenced cognitive
impairment.
Gastrointestinal symptoms were reported in both NG
and PO fed individuals with AN, consistent with
the literature detailing GI distress as a complication and
challenge for this population (Kuyumcu et al., 2013;
Salvioli et al., 2013). This is particularly significant as GI
distress is associated with anxiety (Haug, Mykletun, &
Dahl, 2004; Jansson et al., 2007), and there are high rates
of comorbid anxiety found in individuals with AN
(Godart et al., 2003). In populations with GI-specific
diagnosis, such as irritable bowel syndrome, it has been
reported that anxiety regarding GI symptoms negatively
impacts quality of life and increases reported symptom
severity (Jerndal et al., 2010). Furthermore, the literature
has suggested that those with a history of eating disorders
that present with functional gastric disorders (dyspepsia,
nausea, abdominal pain, and others) report more psycho-
logical distress than those without a past history of eating
disorders (Porcelli, Leandro, & De Carne, 1998). It may
be important in this population to further develop inter-
ventions that address the connection between GI distress,
psychiatric symptoms, and intake in order to promote oral
feeding over the need for NG feeding.
It is of critical importance for clinicians treating indi-
viduals diagnosed with AN to be aware of and prevent
refeeding syndrome. However, nutritional rehabilitation
guidelines with regard to rate of feeding, caloric prescrip-
tion, best practices after acute food refusal, and other sug-
gested predictors of refeeding syndrome remain
incomplete and varying practices exist (Kohn et al., 2011;
Wagstaff, 2011). With regard to safety and prevention of
refeeding syndrome, the data cultivated from individuals
fed via NG may contribute significantly to furthering the
understanding and prevention of refeeding syndrome. Of
concern, only 11 (57%) of studies reported any aspect of
this important clinical consideration. The literature pre-
sented here was promising in that no cases of more than
“minimal” refeeding syndrome were reported. However,
up to 30% of participants demonstrated early signs of
refeeding syndrome such as hypophosphatemia, hypoka-
lemia, and edema, which may be of equal clinical impor-
tance. It remains unclear whether NG feeding has any
effect on the development of refeeding syndrome.
Up to 30% of participants attempted to manipulate
their tube or feeding regimen. Tube manipulation may
indicate an underlying fear of nutritional intake and sub-
sequent weight gain. It would be interesting to further
describe when tube manipulation occurred and to eluci-
date if tube manipulation was reduced over the treatment
course as weight restoration was achieved. Additionally,
Paccagnella et al. (2006) reported that anxiety had a sig-
nificantly negative effect on the willingness for treatment
in the early phases of the study. This suggests that anxi-
ety, not necessarily the feeding modality, may have
greater influence on treatment compliance when individ-
uals are low weighted. This is consistent with previous
literature that states that psychiatric symptoms, including
Kells and Kelly-Weeder 465
anxiety, improve with weight restoration (Accurso et al.,
2014). Anxiety reduction should be of consideration for
treatment planning during the initial phases of psychiatric
treatment, as reduction in anxiety could improve overall
treatment adherence.
Tube manipulation and patient adherence raises the
question of the ethics of feeding individuals against their
will. This represents what Silber (2011) terms “justified
paternalism,” or the overriding of patient autonomy due
to the extreme circumstances of imminent physical dan-
ger as well as the underlying fear of eating characteristic
of the disease. In this, the benefits of NG tube feeding,
including weight gain and the ability to carefully track
fluid volume and caloric intake, are measured along with
the risks of the modality mentioned earlier. Although it is
not within the scope of this article to provide an in-depth
discussion of the ethics at the center of feeding individu-
als diagnosed with AN, the outcomes of the studies pre-
sented here must be taken into account when considering
the use of justified paternalism.
Limitations
This review has several limitations. Eliminating studies
not written in English (n = 4) may have eliminated studies
that may have contributed significant information and
may have influenced the final results. Furthermore, an
overwhelming number of the studies were retrospective
and nonexperimental in nature. Although this highly vul-
nerable, challenging population may make retrospective,
nonexperimental designs clinically and ethically feasible,
drawing meaningful conclusions is more difficult.
Additionally, a lack of consistency in variables studied
and measurement tools used makes comparisons and con-
clusions regarding outcomes difficult. Time to weight or
BMI gain as well as the duration of hospitalization also
varied across studies, thus making direct comparisons
challenging. Additionally, the mean composite score,
reflecting the overall quality of the literature, was moder-
ate. Weak ratings on quality assessment tools were most
frequently the result of less rigorous designs (case stud-
ies, retrospective designs) and subsequent quality issues
including selection biases and inability to blind.
Conclusion
The results of this review suggest that NG feeding may be
of benefit for weight gain in individuals with AN.
However, other outcomes of this treatment modality are
understudied and poorly understood. Additionally, many
of the studies reported are of less rigorous methodologi-
cal quality and conclusions drawn should be taken with
caution. Further research that examines the use of NG
feeding in individuals diagnosed with AN using rigorous
methods is critical to develop comprehensive practice
guidelines and policies for this population.
Author Roles
Meredith Kells completed research and was primary author on
paper.
Susan Kelly-Weeder assisted in writing and editing paper.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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