PAGE 12 NSW HEALTH Guidelines for the Inpatient Management of Adult Eating Disorders in General Medical and Psychiatric Settings in NSW
Managing Refeeding Syndrome
Every LHD has access to a clinical dietitian with expertise in managing malnutrition and refeeding syndrome,
and most districts will have a local policy relating to its management. Reference to the local policy should be
made, and prompt referral to the clinical dietitian should be made before beginning a refeeding regime. The
dietitian can assist in determining whether oral or NG feeding is recommended.
Re-feeding Syndrome is the term used to describe the adverse metabolic effects and clinical complications when a
starved or seriously malnourished individual commences refeeding. If nutrition is not managed carefully, a variety of
detrimental effects can occur including:
– sensory disturbances, confusion, depression, irritability
– glucose intolerance, hyperglycaemia, polyuria
– impaired muscle contraction (including heart, respiratory and gastrointestinal muscles)
– neuromuscular weakness
– reduced oxygenation of tissues, ventilation difficulties
– cardiac arrhythmias
– cardiac arrest.
Confusion (delirium) is often the first sign, accompanied by chest pains, muscle weakness, and then heart failure.
Avoidance of the syndrome can be achieved by prophylactic supplementation of phosphate, thiamine and
multivitamins along with gradually increasing nutritional intake beginning with a nutritionally balanced
diet, adequate in protein and fat content.
Managing risk of refeeding syndrome must be balanced against risk of underfeeding the patient; adequate
nutritional supplements along with fat and protein in the diet, should mitigate the risk of refeeding syndrome so as not
to have to slow the feeding rate too much.
Monitor markers of possible refeeding syndrome via clinical observations twice daily and biochemical review
daily (EUC, CMP, ECG).
Avoidance of refeeding syndrome can also be assisted by reducing carbohydrate calories and increasing
supplementation of phosphate.
Feeding rates: (Risk defined above in Table 2: Indicators for Admission).
These rates are guidelines only, and prioritise avoiding re-feeding syndrome. A specified feeding rate devised
with a clinical dietitian (ideally with eating disorder expertise), is always preferable. With all of the above
mentioned strategies in place to avoid re-feeding syndrome, much faster feeding rates can be tolerated by
numbers of patients, and are advisable to avoid under-feeding.
Extreme risk patients (defined in Table 2) High risk patients (defined in Table 2)
Start with 0.5 x estimated BEE (Basal Energy Expenditure) i.e.
approximately 20mL/h
Increase by 200-300Cal every two to three days if tolerated and
biochem is stabilised.
Feeding rate can be increased faster if electrolytes are stable and
prophylactic supplementation continues.
May take many weeks to reach goal rate
Commence with between 0.8 – 1.0 x estimated BEE i.e.
approximately 1000Cal/day or 40mL/h
Increase rate daily or second daily, 20 – 40mL/h at a time,
if tolerated and biochem is stabilised.
Feeding rate can be increased faster if electrolytes are stable
and prophylactic supplementation continues.
May reach goal rate in 2 weeks
Minor or even moderate abnormalities in liver function (e.g. alanine transaminase up to four times the upper limit of
the normal range) should not delay gradual increases in feeding.