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									Refeeding syndrome
   Nutrition Department

• Refeeding syndrome is a potentially fatal
 condition,caused by rapid initiation of
 refeeding after a period of undernutrition

• characterised by hypophosphataemia,
 associated with fluid and electrolyte shifts
 and metabolic and clinical complications
Refeeding syndrome

• Refeeding syndrome is a well described
  but often forgotten condition.
• No RCT of treatment have been published
• Best available evidence for managing the
  conditionguideline NICE 2006/ England
• Cohort studies, case series, and consensus
  expert opinion
How common?
• The true incidence of RS is unknown
• a study of 10 197 hospitalised patients:
  0.43% severe hypophosphataemia
  (malnutrition : one of the strongest risk
• Not contain phosphorus TPN: 100%
  hypophosphataemia (vs 18% if P contain)
• Cohort study in ICU: 34% HP soon after
  feeding was started (SD= 1.9 ±1.1 days)
pathogenesis: prolonged fasting

• preventing protein and muscle breakdown
  (use of ketone bodies and fatty acids as
  the main energy source, ↓
• severely depleted intracellular minerals
  but normal serum concentrations
• Reduction in renal excretion.
pathogenesis: Refeeding
• ↑ glycemia : ↑ insulin and ↓glucagon
• Insulin stimulates glycogen, fat, and
  protein synthesis.(requires P,Mg, cofactors
  such as thiamine)
• absorption of potassium into the cells
  through the Na,K ATPase symporter (
  transports glucose into the cells)
• Water follows by osmosis
• ↓ P: ↓ATP, change in O2 delivery to tissues, acid base buffer,
  cell membranes integrity.

• ↓ K: derangements in the electrochemical membrane
  potentialarrhythmias and cardiac arrest.

• ↓ Mg: cardiac dysfunction, neuromuscular complications
• Vitamin deficiency: B1  Wernicke’s encephalopathy (ocular
  abnormalities, ataxia, confusional state, hypothermia, coma) or
  Korsakoff’s syndrome (retrograde and anterograde amnesia,

• Sodium, nitrogen, and fluid: rapid ↓ in renal excretion of
  sodium and water cardiac failure, pulmonary oedema, and
  cardiac arrhythmia if try to maintain a normal urine output
Prevention: high risk patients
  Criteria from the guidelines of the National Institute for
  Health and Clinical Excellence for identifying patients at
  high risk of refeeding problems (level D recommendations)

*Either the patient has one or more of the following:
• Body mass index (kg/m2) <16
• Unintentional weight loss >15% in the past three to six months
• Little or no nutritional intake for >10 days
• Low levels of potassium, phosphate, or magnesium before feeding

* Or the patient has two or more of the following:
• Body mass index <18.5
• Unintentional weight loss >10% in the past three to six months
• Little or no nutritional intake for >5 days
• History of alcohol misuse or drugs, including insulin, chemotherapy,
   antacids, or diuretics
NICE guidelines recommendation

• Refeeding is started at no more than 50% of
    energy requirements
•   Increased to meet or exceed full needs over 4-7

• High risk patients: tailored to each patient
    Very malnourished patient: cardiac monitoring
•   Correcting electrolyte and fluid imbalances
    before feeding is not necessary and that this
    should be done along with feeding.
  NICE guidelines recommendation
• Vitamin supplementation should also be
 started with refeeding and continued for at
 least 10 days

• Circulatory volume should also be restored.

• Oral, enteral, or intravenous supplements of
 K, P,Ca, Mg should be given unless blood
 levels are high before refeeding
P, Mg supplementation
Treatment of the Malnourished child

• Essential features of the initial feeding are
   – Frequent small feeds of low osmolality and low in
   – Oral or nasogastric feeds (never IV feeds)
   – 100 kcal/kg/day
   – Protein 1-1.5 gm/kg/day
   – Liquid: 130 ml/kg/day (100 if child has severe edema)
   – Continue with breastfeeding but give scheduled
     amounts of formula first
Treatment of the Malnourished child

• Clinical status must be monitored carefully
• Child should be fed every 2 hours for 1st
  day or 2, then every 3 hours until day 6
• If child’s intake does not reach 80
  kcal/kg/day despite frequent feeds,
  coaxing and re-offering, the remaining
  feed should be given by nasogastric tube
Treatment of the Malnourished child

• Return of the appetite is the sign for entering
  the rehabilitation phase
   – Usually about 1 week after admission
• During this phase very high intakes are
  encouraged to support a weight gain of > 10
   – Must be alert to avoid heart failure (rapid pulse and
     fast breathing) if intake is high suddently)
• Modified porridges or complementary foods can
  be used if comparable in energy an pro
Treatment of the Malnourished child

• Increase each feed by 10 ml until some
  remains uneaten
  – Likely to occur when intakes reach about 200
• After a gradual transition, give
  – Frequent feed, unlimited amounts
  – 150-220 kcal/kg/day
  – 4-6 g/kg/day of protein

• search the databases Medline,Embase, PubMed,
    Cochrane, CINAHL, and AMED (Allied and
    ComplementaryMedicine Database), as well as
    cross checking with reference lists, textbooks,
    and personal reference lists
•   assessed the quality of evidence in original
    articles according to guidelines published on the
    Evidence-Based On-Call website
•   Downloaded from on 22 October 2008
•   Clinical review: Refeeding syndrome: what it is,
    and how to prevent and treat it
    Hisham M Mehanna,Jamil Moledina,Jane Travis
1.  Refeeding Syndrome in a Severely Malnourished Child

2.   Refeeding syndrome Is underdiagnosed and undertreated, but
     Stephen D Hearing, consultant gastroenterologist
     Department of Gastroenterology, Staffordshire General Hospital,
     Weston Road, Stafford

3.   Refeeding syndrome: life-threatening, underdiagnosed, but

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