Refeeding syndrome is a condition that affects people whose diet intake becomes normal again after an extended period of severe malnutrition. The syndrome first came into attention in Americans who were held as prisoners by Japan during World War II. They faced starvation during their days in prison and were affected by the syndrome when they were handed back to the Americans in Philippines after the war.

What Is Refeeding Syndrome?

This is a syndrome that metabolic disturbances occur due to reinstitution of nutrition to patients who are severely malnourished or starved. The main cause is the shift in electrolyte and fluid balance in the body of a person who moves from being severely malnourished and underfed diet to a well nourished one, be it artificial, enterally or parenterally. The shift occurs because of metabolic as well as hormonal changes in the body.

A number of complicated clinical conditions can arise because of this fatal shift. The major condition of the syndrome is hypophosphataemia. Other conditions that can arise because of the syndrome include thiamine deficiency, hypomagnesaemia, hypokalaemia, abnormal fluid as well as sodium balance and change in the metabolism of fat, protein and glucose. 

How Does the Syndrome Develop?

A number of complications can arise because it creates an electrolyte and fluid imbalance and disorder in the body. Along with hypophosphataemia, cardiac, pulmonary, hematologic, neuromuscular and neurologic conditions can also occur in a person because of the syndrome. Individuals who have had an insignificant intake for 5 successive days are at the risk of developing the syndrome. The complications because of the syndrome start to appear within 4 days after the start of refeeding.

The main cause of the syndrome is the continuous period of starvation faced by the body. A long period of malnutrition affects the body’s metabolism significantly. Since the body does not receive a considerable quantity of nutrients, it reduces the production of insulin, thereby reducing the production of carbohydrates. With the level of carbohydrates going down, the body starts producing energy using the reservoirs of fats and proteins.

In case the body has to rely on fats and protein for energy production for a long time, the electrolyte balance in the body shifts. An imbalance in potassium, phosphorus and calcium contents of the body is created. Moreover, since the stomach also has to perform less processing, it also lowers its enzyme production. There is also the chance of reduction in the level of thiamine. 

Symptoms of Refeeding Syndrome

Most of the symptoms of the syndrome appear because of an imbalance of different electrolytes in the body. Different electrolytes like magnesium, potassium and phosphorus which have a major role are mostly affected. Hypophosphataemia which is caused because of a deficiency in phosphorus leads to the following symptoms:

• Acute heart failure
• Problems in bones
• Hesitation and confusion
• Seizures

In case magnesium levels in the body become significantly low in the syndrome known as hypomagnesaemia, following symptoms can arise:

• Loose motions and diarrhea
• Low calcium level hypocalcaemia
• Tachycardia

In case potassium level in the body plummets, the main symptoms which appear are:

• Problems in respiration, respiratory depression
• Problems in heart
• A cessation of the functioning of heart, cardiac arrest
• Paralysis
• Ileus – obstruction of a part of the intestine

Additional symptoms of the syndrome are:

• A sudden increase in weight
• Insulin resistance or hyperglycemia
• Impaired or abnormal state of mind
• Serum sodium level variation
• Retention of fluids by the body
• Increase in body’s vital signs

Treatment for Refeeding Syndrome

The main treatment option available is the restoration of electrolyte balance in the body by replacing the amount of thiamine in the body. The replacement of thiamine can also treat hypophosphataemia. Vitamin replacement can also be a method of treating the symptoms of the syndrome and must continue for around 10 days. The major electrolytes whose levels in the body are low can also be replaced though any secure means possible. Continuous diagnosis and observation of the patient is the key to treat the syndrome, so electrolyte levels should be closely monitored through urine and blood analysis.

The best way of fighting the condition is prevention which can best be done by spreading awareness about the syndrome. Hospital staff should have understanding about the condition and how it occurs so they can successfully monitor and manage patients who are severely malnourished. The hospital staff should follow established medical guidelines while feeding patients who have gone through a phase of a prolonged period of starvation.

One must also take responsibility of spreading awareness of the condition to people who are known to have eating disorders, because prevention is much better than cure.

Prevention of Refeeding Syndrome

The most important part of preventing the syndrome is the identification of patients who are at a higher risk of developing the condition. A patient can be at a risk if he/she is severely malnourished. Malnourishment can be because of a number of reasons, the major reason being a diminished intake of food. The decrease in food intake can occur because of depression, dysphagia, alcoholism and anorexia nervosa. Increased metabolic demands as in cancer or surgery can also result in malnourishment in a patient.

Another major cause of a patient being undernourished is a reduction in the absorption of nutrients in the body. This can happen in celiac disease or inflammatory bowel disease. The patients who are at the highest risk of developing the condition are those who are facing malnutrition because of any cause for an extended period of time. The risk level of developing the condition increases in patients who are physiologically weak, like patients of dysphagia.

A complete evaluation of the nutritional status of a patient must be carried out before restarting the normal diet and nutrition in a patient. To ensure the prevention of the syndrome, a NICE guideline provided by the British Association of Parenteral and Enteral Nutrition is recommended for the patients at a high risk of developing this syndrome. The guidelines also state that the plasma electrolytes level of major electrolytes like sodium, magnesium, potassium and phosphate as well as glucose should be measured before starting the nutrition. Moreover, any inadequacy should be rectified by closely monitoring the patient’s diet. The NICE guidelines also state that before the start of feeding, patient’s intake of alcohol, nutrition, change of weight over time, psychological and social problems should all be assured.