Refeeding syndrome

Last updated: September 22, 2023

Summarytoggle arrow icon

Refeeding syndrome is a life-threatening condition that can occur when severely malnourished individuals resume eating. This includes individuals with protein-energy malnutrition, eating disorders, chronic alcohol use, prolonged fasting, major surgeries, or critical illnesses. Refeeding in individuals who have physiologically adapted to malnutrition can cause severe hypophosphatemia, hypokalemia, and hypomagnesemia, and trigger thiamine deficiency syndrome. Clinical features include weakness, cardiac arrhythmias, respiratory distress, confusion, seizures, and edema. Diagnosis is based on electrolyte levels and signs of organ dysfunction caused by metabolic derangements. Management is aimed at both treatment and prevention. Measures include gradual reintroduction of nutrition, electrolyte monitoring and repletion, and treatment of complications.

Pathophysiologytoggle arrow icon

Abrupt and/or excessive resumption of nutrition in severely malnourished patients can cause massive insulin release increased displacement of magnesium, potassium, and phosphate (shift from extracellular to intracellular) → phosphate, potassium, magnesium (serum levels) [3]

Clinical featurestoggle arrow icon

Diagnosticstoggle arrow icon

Routine studies

Diagnostic criteria [1]

Diagnosis is based on the occurrence of ≥ 1 of the following within 5 days of restarting or increasing caloric intake in malnourished patients :

Managementtoggle arrow icon

Tailor prevention and treatment measures to patients in collaboration with a dietician. Follow local protocols if available. [1][2][4]

Approach [1][2][4]

Avoid aggressive IV fluid resuscitation in patients at risk of refeeding syndrome to prevent volume overload and third spacing. [2][4]

Monitoring [1]

Caloric intake calculation for refeeding [1]

Adjust existing daily caloric goals (e.g., nutritional goals for anorexia nervosa) according to individual patient needs and risk.

  • Adults
    • Start with 100–150 g of dextrose OR 10–20 kcal/kg for the first 24 hours.
    • Increase by 33% of the daily goal every 1–2 days.
  • Children and infants (ages 28 days to 18 years)
    • Aim to start caloric intake at 40–50% of the daily calorie goal.
    • Start dextrose at a rate of 4–6 mg/kg/minute.
    • Advance by 1–2 mg/kg/minute daily as guided by blood glucose levels to a maximum of 14–18 mg/kg/minute.

Remember to include calories from maintenance IV dextrose and medications infused in dextrose solutions in daily caloric intake calculations.

Management of electrolyte disturbances [1]

Hypophosphatemia is the primary biochemical indicator of refeeding syndrome. [4][5]

Other nutritional support [1]

  • Continue IV thiamine for at least 5–7 days in patients with clinical features of or risk factors for thiamine deficiency in consultation with a nutritionist.
  • Provide daily multivitamins for 10 days.

Acute management checklisttoggle arrow icon

Referencestoggle arrow icon

  1. Reber E, Friedli N, Vasiloglou MF, Schuetz P, Stanga Z. Management of Refeeding Syndrome in Medical Inpatients. J Clin Med. 2019; 8 (12): p.2202.doi: 10.3390/jcm8122202 . | Open in Read by QxMD
  2. da Silva JSV, Seres DS, Sabino K, et al. ASPEN Consensus Recommendations for Refeeding Syndrome. Nutr Clin Pract. 2020; 35 (2): p.178-195.doi: 10.1002/ncp.10474 . | Open in Read by QxMD
  3. Eating Disorders: A Guide to Medical Care. Updated: January 1, 2021. Accessed: July 20, 2022.
  4. American Psychiatric Association. The American Psychiatric Association Practice Guideline for the Treatment of Patients with Eating Disorders. . 2022.doi: 10.1176/appi.books.9780890424865 . | Open in Read by QxMD
  5. Hornberger LL et al. Identification and Management of Eating Disorders in Children and Adolescents. Pediatrics. 2021; 147 (1).doi: 10.1542/peds.2020-040279 . | Open in Read by QxMD

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