Refeeding syndrome is a documented problem encountered during certain situations when a severely malnourished person starts receiving significant energy from oral, enteral or parenteral nutrition support.
It was first named when parenteral nutrition was emerging as a nutrition intervention and malnourished patients received excessive calories, mostly from dextrose.1 There continues to be lack of clear and consistent definition of refeeding syndrome, however key risk factors are known and include those who are malnourished, have a very low BMI or who have received negligible nutrient intake over the last 5 days. 2
The rapid start of metabolism of carbohydrate increases the need for intracellular thiamin and electrolytes (e.g. phosphate, magnesium and potassium). When these nutrients rapidly enter the cells, the result is a decrease in serum levels. In addition, alterations in insulin levels can lead to significant sodium and fluid retention. These metabolic disruptions or are known as 'refeeding syndrome".
But is there one "best" way to create a PES statement that leads to appropriate intervention?
If you look at the guidelines for refeeding malnourished patients you will find that recommendations include screening, assessment/monitoring and evaluation of the following types of data:
-NICE guidelines identify that SNAQ may be used as a screening tool to identify those at risk for refeeding syndrome3
-Nutrition Assessment/Monitoring and Evaluation parameters used prior to initiating feeding and monitoring after initiation of feeding
Aspen Guidelines include criteria for identifying moderate or significant risk for refeeding syndrome using a combination of BMI, amount and rate of weight loss, caloric intake, potassium, phosphorus, or magnesium serum concentrations (hypokalemia, hypophosphatemia, or hypomagnesemia), loss of subcutaneous fat, loss of muscle mass, and presence of higher risk co-morbidities.2
-Nutrition interventions include supplementation of thiamin and electrolytes (phosphate, potassium and magnesium if levels are low) prior to the start of nutrition therapy followed by a gradual increase in energy intake to meet energy requirements by Day 2 to 4 as long as electrolyte levels are stable.
What are the appropriate PES statements?7
If you are using criteria to identify individuals "at risk" for refeeding syndrome prior to initiating feeding, then a dietitian may consider using these two PES statements:
· Starvation related malnutrition, severe, related to prolonged nutrition inadequacies as evidenced by unintentional weight loss (adults- of >20% in 1 year; >10% in 6 months; >7.5% in 3 months; or >5% in 1 month), severe loss of subcutaneous fat stores, and severe muscle loss4
· Predicted Inadequate Nutrient Intake (thiamine, phosphorus, potassium and magnesium) related to increased nutrient need during initiation of refeeding after severe malnutrition as evidenced by diagnosis of severe malnutrition, pre-feeding laboratory values for phosphorus, potassium and magnesium (as applicable) and plan to initiate refeeding to estimated requirements by Day 2.5
However if it is now Day 2 and there are documented electrolyte imbalances, then the dietitian may consider the following that reflect the actual presence of refeeding syndrome:
· Starvation related malnutrition (severe), related to prolonged nutrition inadequacies as evidenced by unintentional weight loss (adults- of >20% in 1 year; >10% in 6 months; >7.5% in 3 months; or >5% in 1 month), severe loss of subcutaneous fat stores, and severe muscle loss4
· Imbalance of nutrients related to increased need for electrolytes and thiamine during refeeding as evidenced by (hypokalemia (data), hypophosphatemia(data), and/or hypomagnesemia (data) with TPN currently contributing 75% of estimated energy needs. 6
It is important to remember there may be alterations in electrolytes from other causes, so the dietitians' clinical judgement is necessary to determine whether the evidence is present that reflects a true refeeding syndrome versus an "Altered nutrition related laboratory values.” 8
There may be situations where an "Altered nutrition-related laboratory value" may be identified first and as the clinical picture becomes more clear, this may be elevated to “imbalance of nutrients” that reflects refeeding syndrome. 6-8
Since refeeding syndrome is associated with SEVERE malnutrition, the clinical picture being represented will usually include the severe malnutrition nutrition diagnoses in addition to an "imbalance of nutrients" if refeeding syndrome has occurred, or "predicted inadequate intake" where it is determined that patient is at risk for developing refeeding syndrome.
Acknowledgements: A special thank you to Ainsley Malone, MS, RDN, LD, CNSC, FAND, FASPEN and Sandra Capra, BSc(Hons), DipNutr&Diet, MSocSc, PhD, for providing input to concepts included in this blog.
1. Weinsier RL, Krumdieck CL. Death resulting from overzealous total parenteral nutrition: the refeeding syndrome revisited. Am J Clin Nutr. 1980; 34: 393-399 https://doi.org/10.1016/j.jpeds.2020.01.042
2. da Silva, JWV et al. ASPEN Consensus Recommendations for Refeeding Syndrome. Nutrition in Clinical Practice. 35(2); 2020 178–195 DOI: 10.1002/ncp.10474
3. Nutrition support in adults: Evidence update August 2013. National Institute for Health and Care Excellence (NICE). Available at: https://www.nice.org.uk/guidance/cg32/evidence/evidence-update-pdf-194887261. Accessed December 4, 2020.
4. Academy of Nutrition and Dietetics. Nutrition Terminology Reference Manual (eNCPT): Dietetics Language for Nutrition Care. Starvation Related Malnutrition (undernutrition) (NC-4.1.1). Reference Sheet. Available at: https://www.ncpro.org/pubs/encpt-en/codeNC-4-1-1 Accessed November 22, 2020.
5. Academy of Nutrition and Dietetics. Nutrition Terminology Reference Manual (eNCPT): Dietetics Language for Nutrition Care. Predicted Inadequate Nutrient Intake (Specify) (NI-5.11.1). Reference Sheet. Available at https://www.ncpro.org/pubs/encpt-en/codeNI-5-11-1 Accessed November 22, 2020
6. Academy of Nutrition and Dietetics. Nutrition Terminology Reference Manual (eNCPT): Dietetics Language for Nutrition Care. Imbalance of Nutrients (NI-5.4). Reference Sheet. Available at https://www.ncpro.org/pubs/encpt-en/codeNI-5-4 Accessed November 22, 2020
7. Matthews,KL, Palmer, MA, Capra SM. The accuracy and consistency of nutrition care process terminology use in cases of refeeding syndrome. Nutrition and Dietetics 2018: 75 p 331-336. DOI: 10.1111/1747-0080.12389
8. Academy of Nutrition and Dietetics. Nutrition Terminology Reference Manual (eNCPT): Dietetics Language for Nutrition Care. Altered Nutrition Related Laboratory Values (Nc-2-2). Reference Sheet. Available at https://www.ncpro.org/pubs/encpt-en/codeNC-2-2, Accessed November 22, 2020