From the Guidelines
Refeeding syndrome symptoms include fluid and electrolyte abnormalities, particularly low phosphate, potassium, and magnesium levels, which can develop when nutrition is reintroduced too quickly in malnourished individuals. Patients may experience heart problems like arrhythmias, palpitations, and heart failure; neurological issues such as confusion, seizures, and weakness; respiratory difficulties including respiratory failure; and gastrointestinal symptoms like nausea and abdominal pain. Other symptoms include muscle weakness, cramping, fatigue, and in severe cases, coma or death. These symptoms typically appear within 2-4 days of refeeding and occur because the body shifts from fat to carbohydrate metabolism, causing insulin release that drives electrolytes into cells, depleting blood levels.
Key Symptoms
- Fluid retention with peripheral oedema
- Congestive heart failure
- Cardiac arrhythmia
- Respiratory failure
- Delirium
- Encephalopathy
- Severe organ dysfunctions Prevention involves slow reintroduction of nutrition with careful monitoring of electrolytes, particularly in high-risk patients such as those with anorexia, chronic alcoholism, or prolonged fasting, as recommended by the ESPEN guidelines 1. Treatment requires immediate correction of electrolyte abnormalities, temporary reduction in feeding rate, and close medical supervision. According to the most recent guideline 1, it is prudent to supply vitamin B1 in daily doses of 200-300 mg as well as a balanced micronutrient mixture, and to monitor and substitute electrolytes such as potassium, phosphate, and magnesium as necessary.
From the Research
Refeeding Syndrome Symptoms
The symptoms of refeeding syndrome can be severe and life-threatening, and may include:
- Electrolyte disturbances, such as low serum concentrations of phosphate, magnesium, and potassium 2
- Metabolic abnormalities, reflecting the change from catabolic to anabolic metabolism 2
- Organ dysfunctions, resulting from abnormal electrolyte and fluid shifts 3
- Symptoms may appear within 2-5 days of re-feeding and can be absent/mild or severe, depending on the pre-existing degree of malnutrition and comorbidities 3
Diagnosis and Management
The diagnosis of refeeding syndrome is challenging due to the lack of a standard definition and the nonspecificity of the symptoms 3. However, a unifying definition and severity classification have been proposed by the American Society for Parenteral and Enteral Nutrition (ASPEN) in 2020 3.
- A risk assessment for refeeding syndrome should be performed for every patient before starting nutritional therapy 4
- Patients at high risk should receive adapted energy and fluid support during the replenishment phase 4
- Continuous evaluation for the occurrence of refeeding syndrome is necessary during nutritional therapy, and appropriate steps should be taken if necessary 4