From the Guidelines
For patients at risk of refeeding syndrome, the recommended initial calorie restriction is 5-10 kcal/kg/day, with gradual increases of 200-300 kcal every 1-2 days as tolerated, as suggested by the most recent and highest quality study 1. This approach is crucial in preventing the dangerous electrolyte shifts and fluid retention that characterize refeeding syndrome.
- The initial calorie restriction should be around 5-10 kcal/kg/day, which is approximately 500-800 kcal/day total.
- Caloric intake should be increased slowly, typically by 25% every 1-2 days if no biochemical or clinical signs of refeeding syndrome develop.
- Carbohydrates should be limited initially as they stimulate insulin release, which drives electrolytes intracellularly and can precipitate refeeding complications.
- Concurrent electrolyte replacement is essential, particularly phosphate, potassium, and magnesium, which should be monitored daily during the refeeding period.
- Thiamine (100-300mg daily) should be administered before initiating feeding and continued for at least 5-7 days, as recommended by 1. The situation is particularly dangerous in patients who have abnormal plasma electrolytes before feeding has even started, and correction of the electrolyte abnormalities using intravenous or oral electrolyte supplements should be undertaken before feeding starts, as suggested by 1. However, the most recent study 1 provides the most up-to-date guidance on calorie restrictions for refeeding syndrome, and its recommendations should be prioritized.
- The risk of developing refeeding syndrome increases with the degree of the patient's nutritional depletion, and the initial energy supply should not exceed 5-10 kcal/kg/day, with a slow increase of energy intake over 4-7 days, as recommended by 1.
- Volume of circulation, fluid balance, heart rate and rhythm, as well as clinical status should be monitored closely during the refeeding period, as suggested by 1.
From the Research
Calorie Restrictions for Refeeding Syndrome
The recommended calorie restrictions for patients at risk of refeeding syndrome are as follows:
- Initial calorie intake should be limited to 10 kcal/kg per day, as stated in the study 2
- Calories can be increased slowly over time, as the patient's body adapts to the reintroduction of nutrition
- A study from 2019 found that high-risk patients received lower initial calories, with an average of 12.8 kcal/kg/day 3
Patient Risk Assessment
Patients at risk of refeeding syndrome include:
- Those who are chronically undernourished
- Those with little to no intake for greater than 10 days
- Patients with dysphagia, particularly head and neck cancer patients 2
- Severely malnourished individuals, who require careful monitoring of feeding resumption 4
Prevention and Management
To prevent refeeding syndrome, the following measures can be taken:
- Identify patients at risk and institute nutrition support cautiously
- Correct and supplement electrolyte and vitamin deficiencies
- Monitor electrolyte levels closely, particularly phosphate, magnesium, and potassium
- Provide thiamine, vitamin B complex, and multi-vitamin supplements with refeeding 2, 4, 5, 6