ASPEN Consensus Recommendations for Refeeding Syndrome.

INTRODUCTION: In the spring of 2017, the American Society for Parenteral and Enteral Nutrition (ASPEN) Parenteral Nutrition Safety Committee and the Clinical Practice Committee convened an interprofessional task force to develop consensus recommendations for identifying patients with or at risk for refeeding syndrome (RS) and for avoiding and managing the condition. This report provides narrative review and consensus recommendations in hospitalized adult and pediatric populations. METHODS: Because of the variation in definitions and methods reported in the literature, a consensus process was developed. Subgroups of authors investigated specific issues through literature review. Summaries were presented to the entire group for discussion via email and teleconferences. Each section was then compiled into a master document, several revisions of which were reviewed by the committee. FINDINGS/RECOMMENDATIONS: This group proposes a new clinical definition, and criteria for stratifying risk with treatment and screening strategies. The authors propose that RS diagnostic criteria be stratified as follows: a decrease in any 1, 2, or 3 of serum phosphorus, potassium, and/or magnesium levels by 10%-20% (mild), 20%-30% (moderate), or >30% and/or organ dysfunction resulting from a decrease in any of these and/or due to thiamin deficiency (severe), occurring within 5 days of reintroduction of calories. CONCLUSIONS: These consensus recommendations are intended to provide guidance regarding recognizing risk and identifying, stratifying, avoiding and managing RS. This consensus definition is additionally intended to be used as a basis for further research into the incidence, consequences, pathophysiology, avoidance, and treatment of RS.

Refeeding syndrome in the gastroenterology practice: how concerned should we be?

Clinical nutrition is emerging as a major area in gastroenterology practice. Most gastrointestinal disorders interfere with digestive physiology and compromise nutritional status. Refeeding syndrome (RS) may increase morbidity and mortality in gastroenterology patients. Literature search using the keywords "Refeeding Syndrome", "Hypophosphatemia", "Hypomagnesemia" and "Hypokalemia". Data regarding definition, pathophysiology, clinical manifestations, risk factors, management and prevention of RS were collected. Most evidence comes from case reports, narrative reviews and scarse observational trials. RS results from the potentially fatal shifts in fluid and electrolytes that may occur in malnourished patients receiving nutritional therapy. No standard definition is established and epidemiologic data is lacking. RS is characterized by hypophosphatemia, hypomagnesemia, hypokalemia, vitamin deficiency and abnormal glucose metabolism. Oral, enteral and parenteral nutrition may precipitate RS. Awareness and risk stratification using NICE criteria is essential to prevent and manage malnourished patients. Nutritional support should be started using low energy replacement and thiamine supplementation. Correction of electrolytes and fluid imbalances must be started before feeding. Malnourished patients with inflammatory bowel disease, liver cirrhosis, chronic intestinal failure and patients referred for endoscopic gastrostomy due to prolonged dysphagia present high risk of RS, in the gastroenterology practice. RS should be considered before starting nutritional support. Preventive measures are crucial, including fluid and electrolyte replacement therapy, vitamin supplementation and use of hypocaloric regimens. Gastroenterology patients must be viewed as high risk patients but the impact of RS in the outcome is not clearly defined in current literature.

Dietitians' opinions regarding refeeding syndrome, clinical guidelines and extended scope of practice.

AIM: Refeeding syndrome (RFS) prevalence rates vary across studies depending on the criteria used for assessment and identification. For registered dietitians, the assessment and management of RFS is highly reliant on daily serum electrolyte values; however, registered dietitians working within Australia do not currently possess laboratory test ordering privileges. We aimed to examine the opinions of registered dietitians regarding RFS identification, management and guidelines and the option of using extended scope of practice to order electrolyte monitoring autonomously. METHODS: A multi-method action research approach was used, incorporating two projects. The first was a survey examining Australian registered dietitians' (n = 187) opinions regarding RFS identification, management and guidelines, and autonomous electrolyte monitoring. To establish if results were similar internationally, an interview was conducted with 22 registered dietitians working within 10 different countries. Data were analysed using chi-square tests and thematic analysis. RESULTS: Australian registered dietitians (75%) identify patients at risk of RFS at a high rate of more than once per fortnight, with 74% reporting that they have previously worked with a patient diagnosed with RFS. Results varied internationally, with respondents from eight countries reporting that RFS is a problem within acute care versus respondents from five countries having never treated a patient with RFS. The majority (≥89%) of registered dietitians desire new guidelines and the option to order patient electrolyte monitoring autonomously. CONCLUSIONS: Our findings suggest that more stringent tools for the identification of RFS are necessary. There was limited uniformity across countries, and updated practice guidelines are needed.

[Consensus document about the nutritional evaluation and management of eating disorders: anorexia nervosa]. / Consenso sobre la evaluación y el tratamiento nutricional de los trastornos de la conducta alimentaria: anorexia nerviosa.

Anorexia nervosa is the most common psychiatric disease among young women and it is assumed to be of multifactorial origin. Diagnostic criteria have recently been modified; therefore amenorrhea has ceased to be a part of them. This disease shows a large variability in its presentation and severity which conditions different therapeutic approaches and the need to individualize the treatment, thus it is indispensable a multidisciplinary approach. The goals are to restore nutritional status (through an individualized diet plan based on a healthy consumption pattern), treat complications and comorbidities, nutritional education (based on healthy eating and nutritional patterns), correction of compensatory behaviors and relapse prevention. The treatment will vary according to the patient's clinical situation, and it may be performed in outpatient clinics (when there is clinical stability), in a day hospital or ambulatory clinic (intermediate mode between traditional outpatient treatment and hospitalization) or hospitalization (when there is outpatient management failure or presence of serious medical or psychiatric complications). Artificial nutrition using oral nutritional supplements, enteral nutrition and exceptionally parenteral nutrition may be necessary in certain clinical settings. In severely malnourished patients the refeeding syndrome should be avoided. Anorexia nervosa is associated with numerous medical complications which determines health status, life quality, and is closely related to mortality. There is little clinical evidence to assess the results of different treatments in anorexia nervosa, when most of the recommendations are being based on expert consensus.

[Refeeding syndrome : Pathophysiology, risk factors, prevention, and treatment]. / Refeeding-Syndrom : Pathophysiologie, Risikofaktoren, Prophylaxe und Therapie.

Refeeding syndrome is a life-threatening complication that may occur after initiation of nutritional therapy in malnourished patients, as well as after periods of fasting and hunger. Refeeding syndrome can be effectively prevented and treated if its risk factors and pathophysiology are known. The initial measurement of thiamine level and serum electrolytes, including phosphate and magnesium, their supplementation if necessary, and a slow increase in nutritional intake along with close monitoring of serum electrolytes play an important role. Since refeeding syndrome is not well known and the symptoms can be extremely heterogeneous, this complication is poorly recognized, especially against the background of severe disease and multimorbidity. This overview aims to summarize the current knowledge and increase awareness about refeeding syndrome.

Is refeeding syndrome relevant for critically ill patients?

PURPOSE OF REVIEW: To summarize recent relevant studies regarding refeeding syndrome (RFS) in critically ill patients and provide recommendations for clinical practice. RECENT FINDINGS: Recent knowledge regarding epidemiology of refeeding syndrome among critically ill patients, how to identify ICU patients at risk, and strategies to reduce the potential negative impact on outcome are discussed. SUMMARY: RFS is a potentially fatal acute metabolic derangement that ultimately can result in marked morbidity and even mortality. These metabolic derangements in ICU patients differ from otherwise healthy patients with RFS, as there is lack of anabolism. This is because of external stressors inducing a hypercatabolic response among other reasons also reflected by persistent high glucagon despite initiation of feeding. Lack of a proper uniform definition complicates diagnosis and research of RFS. However, refeeding hypophosphatemia is commonly encountered during critical illness. The correlations between risk factors proposed by international guidelines and the occurrence of RFS in ICU patients remains unclear. Therefore, regular phosphate monitoring is recommended. Based on recent trials among critically ill patients, only treatment with supplementation of electrolytes and vitamins seems not sufficient. In addition, caloric restriction for several days and gradual increase of caloric intake over days is recommendable.

The accuracy and consistency of nutrition care process terminology use in cases of refeeding syndrome.

AIM: Using standardised terminology in acute care has encouraged consistency in patient care and the evaluation of outcomes. As such, the Nutrition Care Process (NCP) and Nutrition Care Process Terminology (NCPT) may assist dietitian nutritionists in the delivery of high quality nutrition care worldwide; however, limited research has been conducted examining the consistency and accuracy of its use. We aimed to examine the NCPT that dietitian nutritionists would use to formulate a diagnostic statement relating to refeeding syndrome (RFS). METHODS: A multimethod action research approach was used, incorporating two projects. The first was a survey examining Australian dietitian nutritionists' (n = 195) opinions regarding NCPT use in cases of RFS. To establish if results were similar internationally, an interview was then conducted with 22 dietitian nutritionists working within 10 different countries. RESULTS: 'Imbalance of nutrients' was only identified as a correct code by 17% of respondents in project 1. No mention of this term was made in project 2. Also 86% of respondents incorrectly selected more than one diagnostic code. The majority of respondents (80%, n = 52/65) who incorrectly selected 'Malnutrition', without also selecting 'Imbalance of nutrients', selected 'reduce intake' as an intervention, suggesting some misunderstanding in the requirement for interrelated diagnoses, interventions and goals. CONCLUSIONS: Our findings demonstrate that there is limited accuracy and consistency in selecting nutritional diagnostic codes in relation to RFS. Respondents also demonstrated limited knowledge regarding appropriate application of the NCP and NCPT. Implementation practices may require further refinement, as accurate and consistent use is required to procure the benefits of standardised terminology.

[Prevention and management of refeeding syndrome in patients with chronic critical illness].

Nutritional support is an important means to treat the patients with chronic critical illness for commonly associated malnutrition. Refeeding syndrome is a serious complication during the process, mainly manifested as severe electrolyte with hypophosphataemia being the most common. Refeeding syndrome is not uncommon but it is often ignored. In our future clinical work, we need to recognize this chinical situation and use preventative and treatment measures. According to NICE clinical nutrition guideline, we discussed the risk factors, treatment methods and preventive measures of refeeding syndrome in patients with chronic critical illness. We argued that for patients with high risk refeeding syndrome, nutritional support treatment should be initially low calorie and slowly increased to complete requirement. Circulation capacity should be recovered, fluid balance must be closely monitored and supplement of vitamins, microelement, electrolytes should be noted. After the emergence of refeeding syndrome, we should reduce or even stop the calorie intake, give an active treatment for electrolyte disorder, provide vitamin B, and maintain the functions of multiple organs.

Refeeding syndrome in Southeastern Taiwan: our experience with 11 cases.

AIM: To present our experience with refeeding syndrome in southeastern Taiwan. METHODS: We conducted a retrospective study during a 2-year period at the Mackay Memorial Hospital, Taitung Branch. We enrolled patients with very little or no nutrition intake for more than 10 d, a high risk group of refeeding syndrome, including those suffering from alcohol abuse, cancerous cachexia, chronic malnutrition, and prolonged starvation. RESULTS: A total of 11 patients (7 males, 4 females) with nasogastric feeding were included as having refeeding syndrome. Most of them had the symptoms of diarrhea, lethargy, and leg edema. The initial nutritional supplement was found to be relatively high in calories (1355.1 ± 296.2 kcal/d), high in protein (47.3 ± 10.4 gm/d), low in vitamin B1 (2.0 ± 0.5 mg/d), low in potassium (1260.4 ± 297.7 mg/d), and low in phosphorus (660.1 ± 151.8 mg/d). Furthermore, hypophosphatemia (2.4 ± 0.9 mg/dL) was noted during follow-up. Based on the suggestions of a dietician and a gastroenterologist, the clinical disorders of diarrhea, malaise and leg edema were significantly improved. The level of phosphate was also increased (3.3 ± 0.6 mg/dL). CONCLUSION: Refeeding syndrome is an overlooked and risky disorder that has some potentially fatal complications. Nasogastric feeding in nursing homes is an important risk factor for patients and deserves greater attention based on the initial results of this study.

Refeeding syndrome in a young girl with anorexia nervosa.

We report the case of a 20-year-old anorexic girl (BMI=12.9), who was misdiagnosed the first time and developed severe electrolyte imbalances due to lack of awareness about refeeding syndrome. Few cases of RS have been reported in literature and protocols have been suggested for prevention and management of this syndrome, including the awareness of circumstances in which it is most likely to develop, refeeding slowly and building-up micronutrient content over several days. Improved awareness and understanding of refeeding syndrome along with a well-coordinated plan are vital in delivering safe and effective nutritional rehabilitation. We suggest a slow and gradual increase in nutrition along with nutritional counselling and psychotherapy.

Refeeding syndrome: screening, incidence, and treatment during parenteral nutrition.

The possible deleterious effects of feeding after a period of prolonged starvation have been known for over 60 years. The resultant biochemical disturbance, symptoms, and signs have been termed the refeeding syndrome (RS). The key to the pathophysiology is the stimulation of insulin release resulting in anabolic activity. Depleted electrolyte and micronutrient stores are overwhelmed and cellular function disrupted. A concise definition of RS is not agreed and hampers interpretation of clinical data. Hypophosphatemia and appearance of tissue edema/pathological fluid shifts are the most often agreed diagnostic criteria. The characteristics of particular patient groups at risk have been recognized for some time, and there are guidelines from the National Institute for Clinical Excellence in the UK to aid recognition of individuals at high risk along with protocols for initiating nutrition. Using loose diagnostic criteria, RS appears to occur in 4% of cases of parenteral nutrition (PN) when case records were reviewed by experts in a large study into PN care in the UK. Disappointingly, prescribers recognized only 50% of at risk cases. Early data from a similar study in New Zealand appear to show a similar pattern. Prospective series looking at patients receiving nutrition support in institutions with Nutrition Support Teams have found an incidence of 1-5%. RS is still underrecognized. Patients receiving PN should be counted as being in a high-risk category and feeding protocols to avoid RS applied. Low rates of RS then occur and death from this cause be avoided.

Refeeding syndrome in children in developing countries who have celiac disease.

OBJECTIVES: The clinical presentations of celiac crisis and refeeding syndrome in celiac disease are almost similar, but information about refeeding syndrome is scarce. We are reporting for the first time 5 cases of refeeding syndrome in children with celiac disease that could have otherwise been labeled as celiac crisis. METHODS: From January to December 2010, a chart review of hospital records of all celiac disease cases was performed, and refeeding syndrome was ascribed in those celiac patients who deteriorated clinically after initiation of a gluten-free diet and had biochemical parameters suggestive of refeeding syndrome such as hypophosphatemia, hypokalemia, hypocalcemia, and hypoalbuminemia. RESULTS: Of the total 35 celiac disease patients, 5 (median age 6.5 [range 2.2-10] years, 3 boys) were identified as having refeeding syndrome. All 5 children were severely malnourished (body mass index <14 kg/m) and all of them had anemia, hypophosphatemia, hypokalemia, hypoalbuminemia, and hypocalcemia, meaning that they had the perfect setting for developing refeeding syndrome. At the same time, their clinical features fulfilled the criteria for celiac crisis except that their symptoms have worsened after the introduction of a gluten-free diet. Nevertheless, instead of using steroids, they were managed as refeeding syndrome in terms of correction of electrolytes and gradual feeding, and that led to a successful outcome in all of them. CONCLUSIONS: Severely malnourished patients with celiac disease are at risk of developing potentially life-threatening refeeding syndrome, which may mimic celiac crisis, especially in developing countries. Early recognition and appropriate treatment are the keys to a successful outcome.

'Refeeding syndrome' in a Kuwaiti child: clinical diagnosis and management.

OBJECTIVE: To report a case of refeeding syndrome in a Kuwaiti child, its clinical presentation and management. CLINICAL PRESENTATION AND INTERVENTION: A 13-month-old Kuwaiti boy presented with acute severe malnutrition in the form of marasmic kwashiorkor. On admission, blood sugar and serum electrolytes were normal but on the 3rd day he developed typical biochemical features of refeeding syndrome in the form of hyperglycemia, severe hypophosphatemia, hypokalemia, hypocalcemia and hypomagnesemia. The child then received treatment appropriate for refeeding syndrome in the form of lower calorie intake with gradual increase, as well as supplementation of electrolytes, thiamine and vitamins and he eventually made a safe recovery. CONCLUSION: This case showed that during rehabilitation of a malnourished child, a severe potentially lethal electrolyte disturbance (refeeding syndrome) can occur. Careful monitoring of electrolytes before and during the refeeding phase was needed and helped to detect this syndrome early. We suggest that slow and gradual calorie increase in the 'at-risk' patient can help prevent its occurrence.

Refeeding syndrome: treatment considerations based on collective analysis of literature case reports.

Refeeding syndrome (RFS) represents a group of clinical findings that occur in severely malnourished individuals undergoing nutritional support. Cardiac arrhythmias, multisystem organ dysfunction, and death are the most severe symptoms observed. As the cachectic body attempts to reverse its adaptation to the starved state in response to the nutritional load, symptoms result from fluid and electrolyte imbalances, with hypophosphatemia playing a central role. Because guidelines for feeding the malnourished patient at risk for refeeding syndrome is scarce, we have provided management recommendations based on the knowledge derived from a collection of reported English literature cases of the RFS. A MEDLINE search using keywords including "refeeding syndrome," "RFS," and "refeeding hypophosphatemia" was performed. References from initial cases were utilized for more literature on the subject. We have emphasized the continued importance of managing patients at risk for RFS, compared how management of the severely malnourished patients have evolved over time, and provided comprehensive clinical guidelines based on the sum of experience documented in the case reports for the purpose of supplementing the guidelines available. Based on our review, the most effective means of preventing or treating RFS were the following: recognizing the patients at risk; providing adequate electrolyte, vitamin, and micronutrient supplementation; careful fluid resuscitation; cautious and gradual energy restoration; and monitoring of critical laboratory indices.

Refeeding syndrome--awareness, prevention and management.

BACKGROUND: Refeeding syndrome is an important, yet commonly overlooked condition affecting patients. It occurs when feeding is commenced after a period of starvation. Head and neck cancer patients are at particular risk owing to prolonged periods of poor nutritional intake. This may be from general effects such as cancer anorexia or from more specific problems of dysphagia associated with this group of patients. Awareness of the condition is crucial in identifying patients at risk and taking measures to prevent its occurrence. OBJECTIVES: The aims of this review are to: 1) Highlight the condition and stress the importance of its consideration when admitting head and neck cancer patients. 2) Discuss the pathophysiology behind refeeding syndrome. 3) Review the literature for the best available evidence and guidelines. 4) Highlight the need for further high quality research. CONCLUSION: Refeeding syndrome is potentially fatal, yet is preventable. Awareness and identification of at-risk patients is crucial to improving management. Refeeding syndrome is caused by rapid refeeding after a period of under-nutrition, characterised by hypophosphataemia, electrolyte shifts and has metabolic and clinical complications. High risk patients include the chronically under-nourished and those with little intake for greater than 10 days. Patients with dysphagia are at particular risk. Refeeding should commence at 10 kcal/kg per day in patients at risk, and increased slowly. Thiamine, vitamin B complex and multi-vitamin supplements should be started with refeeding. New NICE guidelines state that pre-feeding correction of electrolyte and fluid deficits is unnecessary, but should be done concurrently with re-feeding. More research in this field is needed as the evidence base is lacking.