Prevention and management of refeeding syndrome.

Prevention and management of refeeding syndrome

To ensure adequate prevention, the NICE guidelines recommend a thorough nutritional assessment before refeeding is started.

Recent weight change over time, nutrition, alcohol intake, and social and psychological problems should all be ascertained.

Plasma electrolytes (especially phosphate, sodium, potassium, and magnesium) and glucose should be measured at baseline before feeding and any deficiencies corrected during feeding with close monitoring.

For decades, the key to preventing the syndrome was believed to be lower-calorie refeeding with cautious advancement. preventing the syndrome

The NICE guidelines recommend that refeeding is started at no more than 50% of energy requirements for the 1^st 2 days in " patients who have eaten little or nothing for more than 5 days.” The rate can then be increased if no refeeding problems are detected on clinical and biochemical monitoring.

The prescription for people at high risk of developing refeeding problems should consider:

·      starting nutrition support at a maximum of 10 kcal/kg/day, increasing levels slowly to meet or exceed full needs by 4 to 7 days.

·    using only 5 kcal/kg/day in extreme cases (for example, BMI less than 14 kg/m2 or negligible intake for more than 15 days) and monitoring cardiac rhythm continually in these people and any others who already have or develop any cardiac arrythmias.

·     restoring circulatory volume and monitoring fluid balance and overall clinical status closely.

·     providing immediately before and during the first 10 days of feeding: oral thiamin 200 to 300 mg daily, vitamin B co strong 1 or 2 tablets, 3 times a day (or full dose daily intravenous vitamin B preparation, if necessary) and a balanced multivitamin or trace element supplement once daily.

·   providing oral, enteral or intravenous Maintenance requirement of potassium (likely requirement 2 to 4 mmol/kg/day), phosphate (likely requirement 0.3 to 0.6 mmol/kg/day) and magnesium (likely requirement 0.2 mmol/kg/day intravenous, 0.4 mmol/kg/day oral) unless pre-feeding plasma levels are high; pre-feeding correction of low plasma levels is unnecessary.

The following guidance is a suggestion for possible electrolyte repletion for refeeding syndrome in adolescents with eating disorders:

For hypophosphatemia
level	management
phosphorous 2.5-2.9 mg/dL	Phos-Na- K 1 packet (250 mg) tid
phosphorous 2.0-2.4 mg/dL	Phos-Na- K 2 packets (500 mg) tid
Phosphorous <2 mg/dL.	IV Na-K- Phos 0.24 mmol/kg max 15 mmol/dose, and consider ICU consultation.
For hypokalemia
potassium 3.1-3.4 mmol/L (recheck in 8-12 hours)	extended release KCl 20 mEq PO
potassium 2.5-3.0 mmol/L (recheck in 8-12 hours)	extended release KCl 40 mEq PO
potassium 2.2-2.4 mmol/L	extended release KCl 40 mEq PO stat
potassium <2.2 mmol/L.	IV KCl and consider ICU consultation
For hypomagnesemia
magnesium 1.3-1.7 mg/dL	Mag-oxide 1 tablet (133-200 mg elemental Mg each) bid
magnesium 1.0-1.2 mg/dL	Mag-oxide 2 tablets (133-200 mg elemental Mg each) bid
magnesium <1.0 mg/dL	IV Mg-SO4@50 mg/kg, max 2 g/ dose and consider intensive care consultation

 Declining electrolytes but within the normal range generally do not need to be treated.

Fluid repletion should be carefully controlled to avoid fluid overload as described earlier. Sodium administration should be limited to the replacement of losses. In patients at high risk of cardiac decompensation, central venous pressure and cardiac rhythm monitoring should be considered.

Caution is needed in patients with existing renal impairment, hypocalcaemia (which may worsen), or hypercalcaemia (which may result in metastatic calcification).

References:

Jason M. Nagata and Andrea K. Garber, refeeding syndrome, Nelson 22th ed 2024, Vol 1, ch 63.

Mehanna HM, Moledina J, Travis J. Refeeding syndrome: what it is, and how to prevent and treat it. BMJ. 2008 Jun 28;336(7659):1495-8. doi: 10.1136/bmj. a301. PMID: 18583681; PMCID: PMC2440847.

 National Institute forHealth and Clinical Excellence. Nutrition support in adults. Clinical guideline CG32. 2006. www.nice.org.uk/page.aspx?o=cg032