Preventing Refeeding Syndrome in Malnourished Patients

Preventing refeeding syndrome rather than treating it after the fact should be a priority because refeeding syndrome can lead to serious, potentially life-threatening complications. Preventing refeeding syndrome ensures safe nutritional rehabilitation, minimizes health risks and promotes effective recovery.

Refeeding syndrome prevention

When the refeeding process is initiated for individuals with severe eating disorders or malnutrition, they are at risk for developing refeeding syndrome.

Refeeding syndrome consists of a variety of medical complications that develop due to a potentially fatal shift in fluids and electrolytes that occurs in significantly malnourished patients receiving oral, enteral or parenteral nutrition.

Refeeding syndrome symptoms

While there are no criteria indicating a patient will definitively develop refeeding syndrome, all patients who are malnourished are at risk. Some of these conditions and populations include:

• Severe eating disorders, like anorexia nervosa or ARFID
• Chronic alcoholism
• Cancer
• AIDS
• Chronic pancreatitis
• Cystic fibrosis
• Short bowel syndrome
• Inflammatory bowel disease, like Crohn’s disease or ulcerative colitis
• Postoperative patients
• Bariatric surgery patients
• Patients with profound weight loss
• Elderly patients
• Long term users of antacids or diuretics

How to prevent refeeding syndrome

While refeeding syndrome can be treated, prevention is of the utmost importance. Refeeding syndrome can put patients at risk for a variety of severe medical complications, including respiratory failure, seizures, hemolysis and heart failure as well as death. Because of the risks and potential mortality of refeeding syndrome, prevention should be prioritized.

Monitor lab values

Lab values offer valuable insight into the development of refeeding syndrome. Low serum levels of specific electrolytes, including phosphate, magnesium and potassium are the leading indicators of refeeding syndrome.

Other lab tests, like thiamin deficiency (vitamin B1), elevated creatine phosphokinase (CPK) and acute worsening of anemia can suggest development of refeeding syndrome.

Correct lab abnormalities before refeeding

Lab abnormalities should be corrected before the initiation of aggressive refeeding. Electrolyte deficiencies prior to refeeding significantly increase the risk for development of the refeeding syndrome.

Increase calories with caution

Nutritional rehabilitation for a malnourished or eating disorder patient should be individualized and increasing caloric intake should be based on the expert opinion of a registered dietician and other clinical team members who have specialized knowledge of malnutrition and eating disorders.

Weight gain early in the refeeding process can also be very slow as the body switches from a catabolic state to an anabolic state. Even though it might seem like increasing calories to make up for lagging weight gain, it is important not to drastically increase dietary calories too aggressively during this time.

Clinically monitor patients

During the refeeding process, you should not only monitor lab results but also look out for the physical manifestations and complications that result from refeeding syndrome. This can include:

• Worsening fatigue
• Increasing weakness due to rhabdomyolysis or muscle breakdown
• Hypokalemia
• Hypophosphatemia
• Difficulty breathing due to weakness of the diaphragm muscle
• Seizures
• Edema
• Heart failure
• Hemolysis (breakdown of red blood cells)

Refeeding syndrome treatment

While prevention is the best treatment, if refeeding syndrome is suspected, a patient should be hospitalized and aggressive correction of electrolytes needs to occur, either orally or through the intravenous route, depending on the serum values.

Patients will also require very close cardiorespiratory monitoring given the increased risk of cardiac complications, close monitoring of lab values, vitamin supplementation and close monitoring of nutritional intake along with daily weights.

Last Updated: October 2024 by Dennis Gibson, MD, FACP, CEDS

References

• Brown CA, Sabel AL, Gaudiani JL, Mehler PS. Predictors of hypophosphatemia during refeeding of patients with severe anorexia nervosa: predictors of hypophosphatemia. The International Journal of Eating Disorders 2015;48(7):898-904.
• Da Silva JS, et al. ASPEN Consensus Recommendations for Refeeding Syndrome. Nutrition in Clinical Practice 2020;35(20):178-95.
• Mehler PS and Andersen AE (eds). Eating Disorders: A comprehensive guide to medical care and complications (4^th ed.). 2022. John Hopkins University Press.
• Nutritional Rehabilitation: Practical Guidelines for Refeeding the Anorectic Patient - PMC (nih.gov)
• Refeeding syndrome: what it is, and how to prevent and treat it - PMC (nih.gov)