Adults At Risk Of Re-Feeding Syndrome in Primary Care (219)


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A guideline is intended to assist healthcare professionals in the choice of disease-specific treatments.

Clinical judgement should be exercised on the applicability of any guideline, influenced by individual patient characteristics. Clinicians should be mindful of the potential for harmful polypharmacy and increased susceptibility to adverse drug reactions in patients with multiple morbidities or frailty.

If, after discussion with the patient or carer, there are good reasons for not following a guideline, it is good practice to record these and communicate them to others involved in the care of the patient.

Re-feeding Syndrome

Re-feeding syndrome is a combination of metabolic and biochemical changes that are seen when nutritional support is commenced in those who have been in a starved or fasted state. Re-feeding can occur on the initiation of oral, enteral or parenteral nutritional support.

Patients at Risk

Any patient who has had very little or no food intake for >5 days.

Patients at High Risk of developing Re-feeding Syndrome

A patient has 1 or more of the following:

  • BMI (Body Mass Index) less than 16kg/m²
  • Unintentional weight loss greater than 15% within the last 3-6 months
  • Very little or no nutritional intake for more than 10 days
  • Low levels of potassium, phosphate or magnesium prior to feeding

OR a patient has 2 or more of the following:

  • BMI less than 18.5 kg/m²
  • Unintentional weight loss greater than 10% within the last 3-6 months
  • Little or no nutritional intake for more than 5 days

Patients at Extremely High risk of developing Re-feeding Syndrome

  • BMI ˂14kg/m²
  • Very little or no nutrition for ˃15 days

Risk Management Plan

Assess Risk

Establish BMI, degree of unintentional weight loss in the last 3-6 months, period of little or no nutritional intake, potassium magnesium and phosphate levels and any history of excess alcohol or drugs such as insulin, chemotherapy antacids and diuretics.

Those at high risk/extremely high risk of developing re-feeding syndrome should be cared for by healthcare professionals who have the skill, training and expert knowledge of nutritional requirements and nutrition support. Advice from or referral to a dietitian should be sought immediately.

Further information on re-feeding can be found via the following links - (updated May 2014).

Last reviewed: 09 November 2020

Next review: 01 December 2022

Author(s): Michelle Wardrop

Version: 2

Author Email(s): [email protected]

Approved By: Primary Care Prescribing Management Group

Document Id: 219