Table 2 Standard protocol for inpatient refeeding and adjusted protocol for patients with Avoidant/Restrictive Food Intake Disorder

Overlap in protocol

Unique aspect of standard protocol

Unique aspect of adjusted protocol

Caloric goals and monitoring

1. At admission, initiate 2,000 kcal diet unless determined to be high risk for refeeding syndrome

1. Protocol of increasing calories daily, calorie counting, and having meals determined by diet technician remains constant

1. Once medically stable enough, patients are transitioned from standard protocol to modified

2. Increase by 200 kcal every day until at estimated goal kcal

3. Modify rate and amount of calorie increase as needed to support medical stabilization

Meal structure

1. 3 meals and 3 snacks provided daily

1. No use of commode/bathroom within 15 min after meals

1. Meal observations (and commode privileges) may be more flexible (e.g., patients may not need observation after meals or have to wait to use bathroom)

2. 30 min meals, 20 min snacks, 15 min nutritional supplement (if food is not completed)

3. Patient care attendant observes meal/snack and observes after meal/snack for 15 min

4. Family members encouraged to provide mealtime support. If caregiver is available and deemed safe, asked to fill in meal supervision role during later part of admission

Meal content

1. Meals and snacks are delivered by hospital kitchen

1. Meal content determined by diet technician based on available foods and calorie goal for the day

1. Meal content determined by caregiver and patient, if appropriate. Family provided with regular hospital menu, caloric goal and menu planning worksheet. Menus repeated daily as appropriate with modifications made to support increasing calorie goals

2. No dietary modifications made except in case of food allergies, religious needs, and longstanding vegetarianism predating onset of illness. Vegan diets not accommodated

2. Dietary modifications allowed to preference intake of solid nutrition as long as fitting within close range of calorie goals

Calorie/meal replacement

1. Percentage of meal eaten recorded by patient care attendant. Any nutrition not consumed via food is supplemented with nutritional beverage with a 1–1 cal replacement

1. Nursing staff can modify amount of replacement if patient ate mostly high caloric density or low caloric density foods

2. If all nutrition (food and supplement) not completed, supplement is given through nasogastric tube

2. If patient has aversion to supplement, alternate meal replacement items can be used if available to decrease reliance on nasogastric tube

3. Nasogastric tube feeds are completed directly after unfinished meal or snack

4. Nasogastric tube is removed after 24 h of completing all nutrition by mouth