Refeeding syndrome


A syndrome consisting of metabolic disturbances that occur as a result of reintroduction of nutrition to patients who are starved or severely malnourished.

Patients who have had negligible nutrient intake for 5 consecutive days are at risk of refeeding syndrome.

  • occurs within four days of starting to feed.
  • Patients can develop fluid and electrolyte imbalances such as
  • hypophasphatemia
  • neurologic, pulmonary, cardiac, neuromuscular, and hematologic complications.


  Fig. 3.


  1. During prolonged fasting the body aims to conserve muscle and protein breakdown by switching to ketones derived from fatty acids as the main energy source.
  2. The liver decreases its rate of gluconeogenesis thus conserving muscle and protein.
  3. Many intracellular minerals become severely depleted during this period, although serum levels remain normal.
  4. Insulin secretion is suppressed in this fasted state and glugagon secretion is increased.
  5. During refeeding, insulin secretion resumes in response to increased glycemia; resulting in increased glycogen, fat and protein synthesis.
  6. This process requires phosphates, magnesium and potassium which are depleted.
  7. Remaining stores are rapidly used up.
  8. Formation of phosphorylated carbohydrate compounds in the liver and skeletal muscle depletes intracellular ATP and 2,3-diphosphoglycerate in the red blood cells, leading to cellular dysfunction and inadequate oxygen delivery to the body’s organs.
  9. Refeeding increases the body’s basal metabolic rate.
  10. Intracellular movement of electrolytes occurs along with a fall in the serum electrolytes including phosphate, potasium and magnesium.
  11. Glucose, and levels of the B vitamin thiamine may also fall.
  12. Cardiac arrhythmias are the most common cause of death from refeeding syndrome, with other significant risks including confusion, coma and convulsions and cardiac failure.

Assessment, treatment and management:

Refeeding syndrome can be fatal if not recognized and treated properly.

Refeeding syndrome occurs most commonly in those who have lost weight rapidly.
The electrolyte disturbances of the refeeding syndrome can occur within the first few days of refeeding, which can be undertaken through the oral or nasogastric or G tube routes.

Milk is often the refeeding food of choice in this early period as it is naturally high in phosphate and easily tolerated by those who have been starved.

If potassium, phosphate or magnesium are low then these deficiencies should be corrected with supplements.

Prescribing thiamine, vitamin B complex (strong) and a multivitamin and mineral is recommended.

Electrolytes/Biochemistry should be monitored regularly until it is stable.

Dietary intake should remain only 50-70% that of normally required for the first 3–5 days.

Patients who have been starved for some time often experience gastrointestinal disturbance during refeeding:

  • colicky abdominal pain
  • Reflux symptoms
  • Nausea
  • Early sensation of fullness


Pro-kinetic agents such as maxeran

Acid suppressants such as omeprazole


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