Refeeding Syndrome

This fact sheet outlines refeeding syndrome in individuals with eating disorders.

Refeeding syndrome is characterised by the occurrence of cardiac failure, delirium and death(1) due to the metabolic derangements that can occur during the refeeding of a malnourished individual.

Refeeding syndrome is thought to occur when a body in starvation receives an ‘influx of enteral glucose, causing an insulin surge, driving glucose, fluid and electrolytes into the intracellular space’(2) resulting in a rapid reduction of already depleted stores of serum electrolytes such as phosphate, potassium and magnesium. This results in hypophosphatemia, cardiac and neurological events and sudden death.

Many refeeding guidelines recommend initiating refeeding with a low caloric intake, and with slow increases in energy intake to avoid refeeding syndrome. However, a balance needs to be established to prevent underfeeding syndrome.

Underfeeding syndrome occurs when individuals lose weight due to an over-cautious refeeding protocol. This can be as risky as refeeding syndrome, as individuals are put at risk of further medical complications, increased cardiac risk and mortality with further weight loss.(3)

Research is beginning to demonstrate that more rapid refeeding with early weight gain can be safe4, contingent upon limiting the number of calories from carbohydrate and maintaining a normal level of serum phosphate.(5,6)

The risk factors for refeeding syndrome include the degree of malnutrition and adaptation to this state, the rate of weight loss irrespective of body mass index, the levels of serum minerals and electrolytes (including phosphate and potassium) and the rate of refeeding specifically the amount of carbohydrate in relation to other nutrients.(1)

Guidelines

For refeeding guidelines please refer to your local hospital’s refeeding guidelines and the clinical practice guidelines for children, adolescents and adults below:

For adults: Guidelines for the Inpatient Management of Adult Eating Disorders in General Medical and Psychiatric Settings in NSW 2014; Developed by the Centre for Eating and Dieting Disorders (now InsideOut Institute)

For children & adolescents: Eating Disorders Toolkit: A Practice-Based Guide to the Inpatient Management of Children and Adolescents with Eating Disorders. NSW Ministry of Health 2017.