Refeeding Syndrome Symptoms and Warning Signs

Guidelines help identify patients at elevated risk for developing this life-threatening complication of reintroducing calories in the early stages of anorexia nervosa treatment.

Refeeding syndrome is a serious and potentially fatal complication of nutritional rehabilitation in patients with severe anorexia nervosa. It occurs in significantly malnourished patients when a diet of increasing calories is initiated orally, by nasogastric (NG) tube and/or delivered intravenously. In patients experiencing refeeding syndrome, a dangerous shift in fluids and electrolytes occurs within the body, resulting in compromised cardiovascular status, respiratory failure, seizures and even death.

The risk for developing refeeding syndrome correlates directly with the extent of weight loss that accompanies anorexia nervosa. In other words, the lower a patient’s weight, the higher their risk for this complication during refeeding. While there is no single definitive marker to identify which patients will develop refeeding syndrome, the National Institute for Health and Clinical Excellence (NICE) has published two sets of criteria for identifying patients at heightened risk for this complication. According to these guidelines, patients at the highest risk for refeeding syndrome meet one or more of the following criteria:

  • Body mass index (BMI) under 16;
  • Weight loss of more than 15 percent of his or her body weight in the past 3 to 6 months;
  • Little to no food for the past 10 or more consecutive days; or
  • A blood test that reveals low levels of phosphorus, potassium or magnesium.

Patients with anorexia nervosa or ARFID may also have significant risk for refeeding syndrome if they meet two or more of the following criteria:

  • BMI under 18.5;
  • Weight loss of more than 10 percent of his or her body weight in the past 3 to 6 months;
  • Little to no food for the past 5 or more consecutive days; or
  • A history of alcoholism or misuse of certain drugs, such as insulin, chemotherapy drugs, diuretics or antacids.

In addition, chronic alcoholism, cancer, uncontrolled diabetes or recent surgery may place a patient with anorexia at elevated risk for developing refeeding syndrome.

It is important to note that only a subset of patients with heightened risk will develop this life-threatening complication during nutritional rehabilitation. However, treatment providers should regularly monitor at-risk patients for symptoms of refeeding syndrome, including:

  • Fatigue
  • Weakness
  • Confusion
  • Difficulty breathing
  • High blood pressure
  • Seizures
  • Irregular heartbeat
  • Edema
  • Heart failure
  • Coma

Refeeding syndrome symptoms and warning signs typically appear early in the refeeding process, and require immediate medical intervention upon observation. Its development is completely predictable. Therefore, it is important for all patients with extreme forms of anorexia and ARFID to initiate nutritional rehabilitation in an inpatient medical setting that specializes in preventing, identifying and managing this potentially fatal complication. 

For more information about refeeding syndrome symptoms and warning signs, contact us.