From the Guidelines
Refeeding syndrome can be prevented by starting nutritional repletion slowly at about 10 kcal/kg/day, with generous supplementation of potassium, magnesium, calcium, and phosphate, and thiamine administration before starting refeeding, as recommended by the most recent and highest quality study 1. To prevent refeeding syndrome, it is essential to identify patients at high risk, including those with severe malnutrition, anorexia nervosa, chronic alcoholism, prolonged fasting, or significant weight loss (>10% in 2-3 months).
- The underlying mechanism involves insulin surge upon carbohydrate reintroduction, causing rapid intracellular shift of phosphate, potassium, and magnesium, which can lead to cardiac arrhythmias, respiratory failure, seizures, and death.
- Monitor serum electrolytes (particularly phosphate, potassium, and magnesium) daily for at least 3 days, and replace deficiencies promptly.
- Multivitamin supplementation is also recommended during the refeeding process.
- If complications develop, slow or temporarily halt nutritional support until electrolyte abnormalities are corrected, as suggested by 1 and 1. The most recent study 1 recommends increasing nutrition only slowly over several days and taking additional precautions to prevent refeeding syndrome, with a strong recommendation and low level of evidence, but based on consensus. It is crucial to prioritize the prevention of refeeding syndrome, as it can be a fatal condition, and the most recent and highest quality study 1 provides the best guidance on how to prevent it.
From the Research
Definition and Characteristics of Refeeding Syndrome
- Refeeding syndrome (RFS) is a severe electrolyte disturbance and metabolic abnormalities in undernourished patients undergoing refeeding, whether orally, enterally, or parenterally 2.
- It reflects the change from catabolic to anabolic metabolism and can be life-threatening if not recognized and managed properly 2, 3.
- The syndrome is characterized by hypophosphatemia, electrolyte shifts, and metabolic and clinical complications 3, 4.
Risk Factors and Patient Identification
- Patients at risk of refeeding syndrome include the chronically undernourished and those with little intake for greater than 10 days 3.
- Patients with dysphagia, such as head and neck cancer patients, are at particular risk due to prolonged periods of poor nutritional intake 3.
- A risk assessment for refeeding syndrome and stratification should be performed before starting nutritional therapy 5.
Prevention and Management
- Refeeding should commence at 10 kcal/kg per day in patients at risk, and increased slowly 3.
- Thiamine, vitamin B complex, and multi-vitamin supplements should be started with refeeding 3.
- Electrolyte supplementation and laboratory monitoring can help prevent the disorder in susceptible patients 6.
- A consensus statement is available, providing guidance from experts in the field on the management of patients at increased risk of refeeding syndrome receiving nutritional therapy 5.
Diagnosis and Treatment
- The diagnosis of refeeding syndrome is not facilitated by the fact that there is no universal agreement as to its definition 2.
- Precise guidelines for diagnosis and treatment of this syndrome were lacking for a long time, but a consensus statement is now available 5.
- The occurrence of refeeding syndrome during nutritional therapy must be continuously evaluated, and appropriate steps taken if necessary 5.