What is refeeding syndrome?
Refeeding syndrome can happen when someone begins to increase their nutritional intake following a period of severe food restriction.
Changes with electrolytes (minerals in blood) and shifts in fluid can occur during initial phases of refeeding. Potassium, phosphate and magnesium blood levels can drop rapidly during this time and this is known as refeeding syndrome.
Complications associated with refeeding syndrome include serious problems with the heart and with breathing.
While it is important to be aware of the risk of refeeding syndrome, there have been more reported deaths from underfeeding in anorexia nervosa than from refeeding syndrome.
Who is at risk of refeeding syndrome?
The following factors are associated with a high risk of developing refeeding syndrome:
- People with a very low weight for their height (e.g. a BMI under 13kg/m2)
- Little or no intake for more than 4 days
- Low electrolytes before increasing intake
- A low white blood cell count
- Certain medical conditions including liver disease, pneumonia and alcohol misuse
Anyone who is at high risk of refeeding syndrome should be initially managed in hospital as frequent monitoring will be needed.
What can be done to manage the risks of refeeding syndrome?
It is important to increase dietary intake gradually if refeeding is to be done at home. For example, increasing to quarter portions, then to half portions and then building up to full portions of 3 meals and 3 snacks per day over the course of approximately 1 week. Your dietitian can provide advice and guidance around building up your intake.
Your GP can be asked to provide a prescription for the following vitamins (please note some GPs will not prescribe vitamins), it is important to take them as directed:
Thiamine 50mg, four times daily (please speak to us if you feel this would be difficult to manage)
Vitamin B Co-Strong, 1-2 tablets, three times daily
An age-appropriate balanced multivitamin e.g. Forceval, Sanatogen or Centrum, one capsule/ tablet daily
These vitamins are available over the counter from pharmacies and may be cheaper to buy over the counter if you pay for prescriptions. You may wish to purchase these vitamins
yourself to not delay treatment. It is recommended you start taking these vitamins before increasing your intake, for the first 10 days of refeeding or until medically stable. You may benefit from taking a multivitamin for longer.
You will need to have blood tests to check your electrolyte levels before starting to increase your intake (you may have had blood tests before being referred in to the service) and you need to have blood tests at least twice per week initially. If your electrolyte levels are low you may need to take additional supplements (as tablets) prescribed by your GP.
It would be especially beneficial to include dairy foods in your diet whilst increasing your intake e.g. milk, cheese and yogurt as these foods contain phosphate.
Please be honest with your team about what you are eating so your risk of refeeding syndrome can be measured correctly to help to keep you safe.
Contact numbers
West Lancashire All Age Eating Disorders Service
East Lancashire All Age Eating Disorders Service
The Bay All Age Eating Disorders Service
Fylde Coast All Age Eating Disorders Service
Central Lancashire All Age Eating Disorders Service
Patient Advice and Liaison Service (PALS)
If you have some concerns, questions or need advice on our services, you can contact the Patient Advice and Liaison Service (PALS) on 0800 234 6088 or email the PALS Team.
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Call 0800 915 4640
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