Practice Based Learning: Refeeding syndrome

Kayla Koch

Presented by Kayla Koch, MD (PGY-1)

Clinical Questions

  • Who is at risk for refeeding syndrome?
  • What is the best initial management in a patient at risk for refeeding syndrome?


  • “Fed” state:
    • Carbs provide most energy needs. Glucose→ insulin→ increased glycogenesis, decreased lipolysis. If glycogen stores maxed, also increases lipogenesis.
  • “Starved” state: Catabolism
    • Glucose falls→ inc glucagon, dec insulin→ glycogenolysis→ energy from protein, fat→ lose body stores (catabolism)→ depletion of K, Ph, Mg→ intracellular stores released
  • “Refeeding” State: Catabolism to anabolism
    • Glucose→ insulin→ ions into cells→ hypo-P, K, Mg→ Na/water retention
    • Reactivation of carb-dependent pathways→ increased thiamine demand
  • RFS – Key Features:
    • Hypophosphatemia
    • Hypokalemia
    • Hypomagnesemia
    • Na and fluid retention
    • Thiamine (B1) deficiency
  • RFS Management:
    • 3 Key Points:
      • Early recognition of those at risk
      • Appropriate refeeding regimen
      • Monitoring frequently

Key Points

  • RFS is metabolic & biochemical changes that occur from reintroduction of feeds after starvation/fasting
  • At risk: Anorexia nervosa, chronic malnutrition, Marasmus, Kwashiorkor, at least 10-14 d fasting/underfeeding, prolonged IV hydration, massive weight loss
  • No consensus on best management strategy, but start slow and monitor frequently
  • More research needed!


Fuentebella J, Kerner JA. Refeeding syndrome. Pediatr Clin North Am. 2009 Oct; 56(5):1201-10.

Khan LU, Ahmed J, Khan S, Macfie J. Refeeding syndrome: a literature review.
Gastroenterol Res Pract. 2011;2011. pii: 410971.

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.

O’Connor G, Nicholls D. Refeeding hypophosphatemia in adolescents with anorexia nervosa: a systematic review. Nutr Clin Pract. 2013 Jun;28(3):358-64.

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