31st January 2024

Refeeding

Gradual refeeding can be commenced in the community or a psychiatric unit in a patient with a low risk of refeeding syndrome. There is a careful balance required to feed gently enough to avoid refeeding syndrome but also to avoid underfeeding the patient. Therefore, decisions on how to feed are usually informed by a dietitian, though manuals, meal plans, and more intricate guidance exist. In medical inpatient settings, refeeding and meal plans are often advised by dietitians, especially when needing to use NG tubes. Food is usually commenced at 20calories/kg/day, increasing gradually over 14 days to aim for a weight gain of 500g/week. Lower rate feeds are used where risk of refeeding syndrome is greater. In addition, supplements are often required, usually as Forceval once daily and Pabrinex (1 pair daily) or Vitamin B Co-strong 1-2 tablets TDS, Thiamine (50mg QDS), and in inpatient environments, phosphate supplements (500mg BD) often as a prophylaxis for refeeding syndromes. Although refeeding is necessary to save the patient’s life, it will also treat some of the psychological symptoms, as a starved brain exacerbates a negative body image, increases obsession with food, and produces a depression-like syndrome to reduce activity and conserve energy. Daily bloods (in those with red flags) to twice weekly or once weekly bloods for at least 2 weeks are needed to monitor for improvement and refeeding syndrome. 

Assessing risk of refeeding syndrome is complex, and little research exists to create a good risk stratification. Indeed, doctors can be falsely reassured as physical signs, including blood tests of significant malnutrition, do not appear until just before the patient collapses. Definitions of refeeding syndrome are also varied and complex; however, the MEED guidelines provide a definition of :

• Phosphate <0.32mmol/L
• Potassium <2.5mmol/L 
• Magnesium <0.5mmol/L
•  Oedema and/or organ dysfunction, i.e. cardiac failure, respiratory failure, pulmonary oedema or significantly raised transanimases.