Hearing outlined how to avoid the refeeding syndrome when feeding a malnourished patient. Feeding should be gradual with careful replacement of deficient electrolytes, especially phosphate. The author is from Staffordshire General Hospital in England.


Feeding a severely malnourished patient can result in a shift in metabolism from fat and protein to carbohydrate. This can result in marked hypophosphatemia and other electrolyte abnormalities, usually within 4 days of starting nutritional therapy.



(1) Determine if the patient is at risk for the refeeding syndrome.

(2) Calculate the daily caloric requirements for the patient.

(3) Measure baseline chemistry panel (serum phosphate, magnesium, calcium, potassium, urea and creatinine) prior to initiation of feeding.

(4) The patient should be started on a diet at 25-50% of estimated requirements.

(5) Repeat chemistry panel periodically at 12 hours after starting nutritional therapy and replete phosphate and electrolyte deficiencies.

(6) Continue to gradually increase caloric intake gradually each day with daily measurement of the chemistry panel.

(7) Replace any continued deficiencies in phosphate or electrolytes.

(8) Most patients can reach full caloric intake within 4 days.


Repletion protocols for serum phosphate are discussed in Chapter 13.


To read more or access our algorithms and calculators, please log in or register.