Preventing Re-Feeding Syndrome -- Hypophosphatemia


By Dr. Julie O’Toole, Kartini Clinic

F.E.A.S.T. Advisor
February 8, 2011


The recent tragic death of the teenage daughter of a parent on the Around the Dinner Table forum has reinforced the need for a clearer understanding of what can go wrong during re-feeding, in any setting.  


Experience with the “re-feeding syndrome”, as it has been referred to, is not new.  It was  documented tragically after the release of internment camp survivors after WWII and has been sporadically reported in patients with anorexia nervosa who were in the early stages of “re-feeding.” All patients should be considered at risk and monitored carefully. Awareness of the possibility of  this treatment complication appears to be our only defense.


Parents who re-feed their children themselves under the direction of a physician, or those whose children are being re-fed in a hospital setting, will want to arm themselves with a basic understanding of this potentially fatal complication. If necessary, parents may need to make their doctors aware of this possibility.  Please do not assume that all physicians understand or are well versed in the re-feeding syndrome: experience with re-feeding syndrome varies a lot.


Who is at risk? Patients with anorexia nervosa who have lost a significant amount of weight, regardless of whether or not their starting point was “overweight.” The full-blown re-feeding syndrome can involve imbalances in a number of things (potassium, glucose, magnesium, vitamins and fluids, etc.), but it is the sudden drop in levels of PHOSPHORUS, an “electrolyte,”  that is extremely dangerous and often over-looked.  A low level of phosphorus  is called HYPOPHOSPHATEMIA. 


HYPOPHOSPHATEMIA takes place when a malnourished patient suddenly takes in glucose (sugar) and the body reacts by releasing insulin into the blood. This causes a chain reaction where phosphorus suddenly goes from the fluid between cells to the inside of cells and becomes unavailable. This sudden shift of phosphorus can cause weakness, inability to breathe, seizures and convulsions, confused mental state and even cardiac arrest.


Unlike electrolyte imbalances that can occur from vomiting and laxatives, the unique thing about HYPOPHOSPHATEMIA is that it worsens with re-feeding.  Because re-feeding is necessary, it is important that medical oversight be prepared to prevent it. Re-feeding Syndrome is preventable.


Preventing Re-Feeding Syndrome means phosphorus levels MUST be checked regularly throughout the initial phase of re-feeding.   Please have this done to safe-guard your child as they begin to eat.


Re-feeding syndrome is rare, but it can be fatal.  If you feel that your physician—or anyone else—is not experienced in preventing Re-Feeding Syndrome, please refer them to the following medical citations. There are many more.


At Kartini Clinic we have not had any cases of fatal RFS and believe in careful medical monitoring.

1.  Cardiac arrest and delirium: presentations of the refeeding syndrome in severely malnourished adolescents with anorexia nervosa.  Kohn MR, Golden NH, Shenker IRJ Adolesc Health. 1998 Mar;22(3):239–243

       2. Hypophosphatemia secondary to oral refeeding in anorexia nervosa.  Fisher M, Simpser E, Schneider M.    Int J Eat Disord. 2000 Sep;28(2):181-7.

       3. Hypophosphatemia following self-treatment for anorexia nervosa.  Winston AP, Wells FE.      Int J Eat Disord. 2002 Sep;32(2):245-8.

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