Is a patient who eats regularly but vomits a few times a week at risk of refeeding syndrome?

From the Guidelines

A patient who eats regularly but vomits a few times a week is generally not at high risk for refeeding syndrome. Refeeding syndrome typically occurs in severely malnourished individuals who have had little to no nutritional intake for an extended period (usually 5-10 days or longer) and then suddenly receive nutrition 1. The condition involves dangerous shifts in fluids and electrolytes, particularly phosphate, potassium, and magnesium, when feeding is reintroduced. For someone who maintains regular eating patterns despite occasional vomiting, their body likely hasn't entered the starvation adaptation state that predisposes to refeeding syndrome. However, if the vomiting becomes more frequent or severe, leading to significant weight loss (>10-15% of body weight), malnutrition, or electrolyte abnormalities, the risk may increase.

Some key points to consider in assessing the risk of refeeding syndrome include:

• The degree of nutritional depletion, with higher risk in those who have had minimal food intake for at least 5 days 1
• The presence of electrolyte abnormalities, such as hypophosphataemia, hypokalaemia, and hypomagnesaemia, which can be monitored and corrected before and during nutritional repletion 1
• The importance of thiamine supplementation, particularly in patients at risk of thiamine deficiency, such as those with a history of inadequate oral intake or certain clinical conditions 1
• The need for close monitoring of volume of circulation, fluid balance, heart rate and rhythm, as well as clinical status, during nutritional repletion 1

In general, patients with eating disorders like bulimia nervosa who vomit regularly should be monitored more closely, and if concerned about nutritional status, checking electrolytes (especially phosphate, potassium, and magnesium) before increasing nutritional intake would be prudent. The most recent and highest quality study on this topic is from 2022, which highlights the importance of early suspicion and recognition of thiamine deficiency in preventing refeeding syndrome 1.

From the Research

Risk of Refeeding Syndrome

The patient in question, who eats regularly but vomits a few times a week, may be at risk of refeeding syndrome due to the potential for malnutrition and electrolyte imbalances.

• The patient's regular eating habits may not be sufficient to prevent malnutrition, especially if the vomiting is frequent enough to lead to a significant loss of nutrients 2.
• Refeeding syndrome can occur in patients who are malnourished, regardless of the underlying cause, and can be triggered by the reintroduction of nutrition after a period of fasting or poor intake 3, 4.
• The risk of refeeding syndrome is not limited to patients with a history of fasting or anorexia nervosa, but can also occur in patients with other conditions, such as pancreatitis or malignancies, who may be at risk of malnutrition and electrolyte imbalances 5, 6.
• It is essential to monitor the patient's electrolyte levels, including phosphate, magnesium, and potassium, and to provide supplementation as needed to prevent refeeding syndrome 2, 5.
• Close monitoring of the patient's nutritional intake and overall health is crucial to prevent and manage refeeding syndrome, regardless of the underlying cause of malnutrition 3, 4, 6.