From the Guidelines
Meal plans should be held in refeeding syndrome when severe electrolyte abnormalities occur, particularly when phosphate levels drop below 2.0 mg/dL, potassium falls below 3.0 mEq/L, or magnesium decreases below 1.5 mg/dL, as recommended by recent guidelines 1.
Key Considerations
- Severe electrolyte abnormalities, such as hypophosphatemia, hypokalemia, and hypomagnesemia, are key indicators for holding meal plans in refeeding syndrome 1.
- Patients at high risk of refeeding syndrome include those with chronic alcoholism, severe chronic undernutrition, anorexia nervosa, or depleted patients with acute illness 1.
- The ESPEN guideline on hospital nutrition recommends starting nutritional therapy with low caloric input and increasing step by step over five to ten days, according to the individual’s risk of refeeding syndrome and clinical features 1.
Management Approach
- When severe electrolyte abnormalities or significant cardiac arrhythmias, severe edema, or respiratory distress occur, immediately stop nutritional advancement and correct electrolyte imbalances with appropriate supplementation 1.
- Monitor electrolytes every 4-6 hours until stable, and then cautiously resume feeding at 25-50% of the previous rate, with gradual advancement over 5-7 days while maintaining close monitoring 1.
Prevention and Risk Assessment
- Screening for patients at risk of refeeding syndrome includes assessing for low BMI, unintentional weight loss, little or no intake for an extended period, or low potassium, phosphate, and magnesium levels before feeding 1.
- The ESPEN practical guideline on clinical nutrition in cancer recommends increasing nutrition only slowly over several days and taking additional precautions to prevent refeeding syndrome in patients with severely decreased oral food intake for a prolonged period 1.
From the Research
Refeeding Syndrome and Meal Plans
When dealing with refeeding syndrome, it is crucial to approach meal plans with caution to avoid exacerbating the condition. The key is to balance the need for nutrition with the risk of refeeding problems.
- Identification of Patients at Risk: It is essential to identify patients at risk of refeeding syndrome, including those who have had no or very little nutrition for over 5 days 2.
- Monitoring and Management: Careful patient monitoring and multidiscipline nutrition team management can help achieve the goal of preventing refeeding syndrome 3.
- Electrolyte Supplementation: Generous vitamin and electrolyte supplementation may be given while monitoring closely and increasing the calorie intake reasonably rapidly from 10 to 20 kcal/kg/24 hours 2.
- Calorie Intake: The calorie intake should be increased gradually, and the patient's appetite restoration is an indication that the risks of refeeding have been managed 2.
- Slowing or Stopping Feed: If problems do occur, the feed should be slowed to the previous day's amount, reduced further, or rarely stopped while fluid and electrolyte issues are corrected 2.
Prevention and Treatment
Preventing refeeding syndrome is crucial, and several strategies can be employed:
- Prophylactic Supplementation: Prophylactic supplementation of phosphate, magnesium, and potassium, in addition to routine thiamin and multivitamin supplementation, can be effective in preventing refeeding syndrome 4.
- Guidelines: Following guidelines, such as the NICE 2006 guideline, can help in the treatment of refeeding syndrome, although the quality of evidence is low 5.
- Individualized Approach: An individualized approach to refeeding, taking into account the patient's specific needs and risk factors, is essential to prevent refeeding syndrome 6.