Skip to main content

Thank you for visiting You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

Nutrition in clinical practice—the refeeding syndrome: illustrative cases and guidelines for prevention and treatment


The refeeding syndrome is a potentially lethal complication of refeeding in patients who are severely malnourished from whatever cause. Too rapid refeeding, particularly with carbohydrate may precipitate a number of metabolic and pathophysiological complications, which may adversely affect the cardiac, respiratory, haematological, hepatic and neuromuscular systems leading to clinical complications and even death. We aimed to review the development of the refeeding syndrome in a variety of situations and, from this and the literature, devise guidelines to prevent and treat the condition. We report seven cases illustrating different aspects of the refeeding syndrome and the measures used to treat it. The specific complications encountered, their physiological mechanisms, identification of patients at risk, and prevention and treatment are discussed. Each case developed one or more of the features of the refeeding syndrome including deficiencies and low plasma levels of potassium, phosphate, magnesium and thiamine combined with salt and water retention. These responded to specific interventions. In most cases, these abnormalities could have been anticipated and prevented. The main features of the refeeding syndrome are described with a protocol to anticipate, prevent and treat the condition in adults.

This is a preview of subscription content, access via your institution

Relevant articles

Open Access articles citing this article.

Access options

Buy article

Get time limited or full article access on ReadCube.


All prices are NET prices.

Figure 1


  • Betrosian AP, Thireos E, Toutouzas K, Zabaras P, Papadimitriou K, Sevastos N (2004). Occidental beriberi and sudden death. Am J Med Sci 327, 250–252.

    Article  Google Scholar 

  • Beumont PJ, Large M (1991). Hypophosphataemia, delirium and cardiac arrhythmia in anorexia nervosa. Med J Aust 155, 519–522.

    CAS  PubMed  Google Scholar 

  • Birmingham CL, Alothman AF, Goldner EM (1996). Anorexia nervosa: refeeding and hypophosphatemia. Int J Eat Disord 20, 211–213.

    CAS  Article  Google Scholar 

  • Brooks MJ, Melnik G (1995). The refeeding syndrome: an approach to understanding its complications and preventing its occurrence. Pharmacotherapy 15, 713–726.

    CAS  PubMed  Google Scholar 

  • Burger GCE, Drummond JC, Sandstead HR (1948). Malnutrition and Starvation in Western Netherlands, September 1944 - July 1945. General State Printing Office: The Hague.

    Google Scholar 

  • Cooke RA, Chambers JB, Singh R, Todd GJ, Smeeton NC, Treasure J et al. (1994). QT interval in anorexia nervosa. Br Heart J 72, 69–73.

    CAS  Article  Google Scholar 

  • Craddock PR, Yawata Y, VanSanten L, Gilberstadt S, Silvis S, Jacob HS (1974). Acquired phagocyte dysfunction. A complication of the hypophosphatemia of parenteral hyperalimentation. N Engl J Med 290, 1403–1407.

    CAS  Article  Google Scholar 

  • Crook MA, Hally V, Panteli JV (2001). The importance of the refeeding syndrome. Nutrition 17, 632–637.

    CAS  Article  Google Scholar 

  • Crook MA, Panteli JV (2005). The refeeding syndrome and hypophosphataemia in the elderly. J Intern Med 257, 397–398.

    CAS  Article  Google Scholar 

  • Cumming AD, Farquhar JR, Bouchier IA (1987). Refeeding hypophosphataemia in anorexia nervosa and alcoholism. BMJ 295, 490–491.

    CAS  Article  Google Scholar 

  • Faintuch J (1990). The refeeding syndrome: a review. J Parenter Enteral Nutr 14, 667–668.

    CAS  Article  Google Scholar 

  • Food and Nutrition Board, Institute of Medicine of the National Academies (2005). Dietary Reference Intakes Table – The Complete Set.

  • Gonzalez Avila G, Fajardo Rodriguez A, Gonzalez Figueroa E (1996). The incidence of the refeeding syndrome in cancer patients who receive artificial nutritional treatment. Nutr Hosp 11, 98–101.

    CAS  PubMed  Google Scholar 

  • Gustavsson CG, Eriksson L (1989). Acute respiratory failure in anorexia nervosa with hypophosphataemia. J Intern Med 225, 63–64.

    CAS  Article  Google Scholar 

  • Hadley SJ, Walsh BT (2003). Gastrointestinal disturbances in anorexia nervosa and bulimia nervosa. Curr Drug Targets C N S Neurol Disord 2, 1–9.

    CAS  Article  Google Scholar 

  • Hearing SD (2004). Refeeding syndrome. BMJ 328, 908–909.

    Article  Google Scholar 

  • Hernandez-Aranda JC, Gallo-Chico B, Luna-Cruz ML, Rayon-Gonzalez MI, Flores-Ramirez LA, Ramos Munoz R et al. (1997). Malnutrition and total parenteral nutrition: a cohort study to determine the incidence of refeeding syndrome. Rev Gastroenterol Mex 62, 260–265.

    CAS  PubMed  Google Scholar 

  • Heymsfield SB, Bethel RA, Ansley JD, Gibbs DM, Felner JM, Nutter DO (1978). Cardiac abnormalities in cachectic patients before and during nutritional repletion. Am Heart J 95, 584–594.

    CAS  Article  Google Scholar 

  • Isner JM, Roberts WC, Heymsfield SB, Yager J (1985). Anorexia nervosa and sudden death. Ann Intern Med 102, 49–52.

    CAS  Article  Google Scholar 

  • Keys A, Brozek J, Henschel A, Mickelsen O, Taylor HF (1950). The Biology of Human Starvation. University of Minnesota Press: Minneapolis.

    Book  Google Scholar 

  • Kraft MD, Btaiche IF, Sacks GS (2005). Review of the refeeding syndrome. Nutr Clin Pract 20, 625–633.

    Article  Google Scholar 

  • Marik PE, Bedigian MK (1996). Refeeding hypophosphatemia in critically ill patients in an intensive care unit. A prospective study. Arch Surg 131, 1043–1047.

    CAS  Article  Google Scholar 

  • Marinella MA (2003). The refeeding syndrome and hypophosphatemia. Nutr Rev 61, 320–323.

    Article  Google Scholar 

  • National Collaborating Centre for Acute Care (2006). Nutrition Support in Adults: Oral Nutrition Support, Enteral Tube Feeding and Parenteral Nutrition. National Collaborating Centre for Acute Care: London. (

  • O'Connor LR, Wheeler WS, Bethune JE (1977). Effect of hypophosphatemia on myocardial performance in man. N Engl J Med 297, 901–903.

    CAS  Article  Google Scholar 

  • Patrick J (1977). Death during recovery from severe malnutrition and its possible relationship to sodium pump activity in the leucocyte. BMJ 1, 1051–1054.

    CAS  Article  Google Scholar 

  • Paula FJ, Plens AE, Foss MC (1998). Effects of hypophosphatemia on glucose tolerance and insulin secretion. Horm Metab Res 30, 281–284.

    CAS  Article  Google Scholar 

  • Powers PS (1982). Heart failure during treatment of anorexia nervosa. Am J Psychiatry 139, 1167–1170.

    CAS  Article  Google Scholar 

  • Rolfe M (1994). Beri-beri: ‘Endemic amongst urban Gambians’. Afr Health 16, 22–23.

    CAS  PubMed  Google Scholar 

  • Schnitker MA, Mattman PE, Bliss TL (1951). A clinical study of malnutrition in Japanese prisoners of war. Ann Intern Med 35, 69–96.

    CAS  Article  Google Scholar 

  • Travis SF, Sugerman HJ, Ruberg RL, Dudrick SJ, Delivoria-Papadopoulos M, Miller LD et al. (1971). Alterations of red-cell glycolytic intermediates and oxygen transport as a consequence of hypophosphatemia in patients receiving intravenous hyperalimentation. N Engl J Med 285, 763–768.

    CAS  Article  Google Scholar 

  • Weinsier RL, Krumdieck CL (1981). Death resulting from overzealous total parenteral nutrition: the refeeding syndrome revisited. Am J Clin Nutr 34, 393–399.

    CAS  Article  Google Scholar 

  • Whyte E, Jefferson P, Ball DR (2003). Anorexia nervosa and the refeeding syndrome. Anaesthesia 58, 1025–1026.

    CAS  Article  Google Scholar 

  • World Health Organisation (1999). Management of Severe Malnutrition: A Manual for Physicians and Other Senior Health Workers. World Health Organisation: Geneva. (

  • World Health Organisation (2004). Severe Malnutrition: Report of a Consultation to Review Current Literature. World Health Organisation: Geneva. (

Download references


AB has been supported by grants from the Swiss Foundation for Nutrition Research and the Swiss Society for Internal Medicine.

Author information

Authors and Affiliations


Corresponding author

Correspondence to D N Lobo.

Additional information

Contributors: ZS: study design, data collection, data interpretation and analysis, preparation of paper and critical review. AB: data collection, data interpretation and analysis, preparation of paper and critical review. ML: data collection and preparation of paper. RFG and AS: data interpretation, preparation of paper and critical review. SPA and DNL: study design, data interpretation and analysis, preparation of paper and critical review.

Conflict of interest

None of the authors has a conflict of interest to declare.

Ethics committee approval

None required.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Stanga, Z., Brunner, A., Leuenberger, M. et al. Nutrition in clinical practice—the refeeding syndrome: illustrative cases and guidelines for prevention and treatment. Eur J Clin Nutr 62, 687–694 (2008).

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI:


  • refeeding syndrome
  • hypophosphataemia
  • hypomagnesaemia
  • thiamine deficiency
  • nutritional therapy
  • guidelines

This article is cited by


Quick links