Refeeding Syndrome in the Acute Setting

Refeeding syndrome occurs after the delivery of artificial nutrition to undernourished or malnourished hospital patients. Patients in the acute setting are particularly at risk and need to be identified and managed.

Why is Refeeding Syndrome Important?

Refeeding syndrome is an important and yet overlooked condition that occurs when feeding is started after a period of starvation. Awareness of the condition is vital to identify those malnourished patients who are at increased risk, so appropriate measures can be taken to prevent it.

Reinstitution of nutrition is central to the management of the malnourished acutely admitted patient population, but it can trigger refeeding syndrome with shifts in fluid balance and metabolic disturbance.

Symptoms of Refeeding Syndrome

Refeeding syndrome is a condition characterised by potentially fatal shifts in electrolytes, particularly phosphates. It can occur in hospital malnourished patients on artificial feeding. It usually occurs within four days of starting to feed.

Most of the consequent effects are due to a shift from fat to carbohydrate metabolism and a sudden increase in insulin. There is increased cellular phosphate uptake and basal metabolic rate which depletes serum electrolyte levels.

Refeeding syndrome may be fatal if not recognised and managed appropriately. If left untreated, then there is significant risk of increasing confusion, coma, convulsions and even death. An awareness of the condition and a high index of suspicion are required in order to make the diagnosis.

Treatment of Refeeding Syndrome

If serum electrolytes are found to be low, eg potassium, phosphate, or magnesium, then they should be corrected. Providing thiamine, mineral supplements and multivitamins including the vitamin B complex is recommended.

Identifying Patients at Risk

NICE Guidelines are used to stratify patients according to increased risk of refeeding syndrome are classified as having two or more minor risk factors and one more major risk factor. These risk factors are based on BMI, unintentional weight loss, nutritional intake, and other factors. Refeeding syndrome is an under-recognised condition which poses considerable risk to hospitalised patients.

Identifying patients is critical to prevent the associated complications of refeeding syndrome. Following the NICE guidelines helps screen high risk patients in the acute hospital setting and aids in early detection and management of this condition.


Successful management of at risk patients requires multidisciplinary cooperation including using the clinical nursing and dietitian services. We are forming a template in conjunction with the dietitian services to form a care pathway to increase the identification of these patients at high risk of refeeding syndrome.

Conor Caffrey writes on health, science and medicine.


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