Intended for healthcare professionals

Clinical Review

Refeeding syndrome: what it is, and how to prevent and treat it

BMJ 2008; 336 doi: (Published 26 June 2008) Cite this as: BMJ 2008;336:1495
  1. Hisham M Mehanna, consultant and honorary associate professor, and director12,
  2. Jamil Moledina, senior house officer 3,
  3. Jane Travis, Macmillan specialist dietitian4
  1. 1Institute of Head and Neck Studies and Education, Department of Otorhinolaryngology—Head and Neck Surgery, University Hospital, Coventry CV2 2DX
  2. 2Heart of England Foundation Trust, Birmingham
  3. 3Department of Otorhinolaryngology—Head and Neck Surgery, University Hospital, Coventry
  4. 4Department of Dietetics, University Hospital, Coventry
  1. Correspondence to: H M Mehanna Hisham.Mehanna{at}

Refeeding syndrome is a well described but often forgotten condition. No randomised controlled trials of treatment have been published, although there are guidelines that use best available evidence for managing the condition. In 2006 a guideline was published by the National Institute for Health and Clinical Excellence (NICE) in England and Wales. Yet because clinicians are often not aware of the problem, refeeding syndrome still occurs.1

This review aims to raise awareness of refeeding syndrome and discuss prevention and treatment. The available literature mostly comprises weaker (level 3 and 4) evidence, including cohort studies, case series, and consensus expert opinion.2 Our article also draws attention to the NICE guidelines on nutritional support in adults, with particular reference to the new recommendations for best practice in refeeding syndrome.3 These recommendations differ in parts from—and we believe improve on—previous guidelines, such as those of the Parenteral and Enteral Nutrition Group of the British Dietetic Association (box 1).4

Box 1 Why use the NICE guidelines on refeeding syndrome?

  • The guidelines are the most recent comprehensive review of the literature on refeeding syndrome

  • The guideline development group was strongly multidisciplinary with wide ranging consultation with both professional and patient stakeholders

  • The guidelines clearly identified points of good practice and areas for further research

  • The new guidelines give explicit clinical criteria for patients “at risk” and “highly at risk” of developing refeeding syndrome, enabling better identification and prevention

  • For patients with electrolyte deficits the new guidelines recommend immediate start of nutritional support at a lower rate, rather than waiting till the electrolyte imbalance has been corrected (as was recommended by previous guidelines), thus potentially avoiding further nutritional deterioration in patients

What is refeeding syndrome?

Refeeding syndrome can be defined as the potentially fatal shifts in fluids and electrolytes that may occur in malnourished patients receiving artificial refeeding (whether enterally or parenterally5). These shifts result …

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