When should I consider referring a patient to a specialist for management of refeeding syndrome?

Consider referring a patient to a specialist for the management of refeeding syndrome when they are at high risk of developing refeeding problems, as defined by specific clinical criteria. These criteria include having a BMI less than 16 kg/m2, unintentional weight loss greater than 15% within the last 3 to 6 months, little or no nutritional intake for more than 10 days, or low levels of potassium, phosphate, or magnesium before feeding. Alternatively, patients with two or more of the following: BMI less than 18.5 kg/m2, unintentional weight loss greater than 10% within the last 3 to 6 months, little or no nutritional intake for more than 5 days, or a history of alcohol abuse or use of drugs such as insulin, chemotherapy, antacids, or diuretics should also be considered high risk and warrant specialist involvement.

Patients at high risk should be managed by healthcare professionals with expert knowledge of nutritional requirements and nutrition support, including careful initiation and monitoring of nutrition support, electrolyte supplementation, and vitamin replacement. Referral is particularly important if the patient requires enteral tube feeding or parenteral nutrition, or if they have extreme risk factors such as BMI less than 14 kg/m2 or negligible intake for more than 15 days, which necessitate very cautious feeding and continuous cardiac monitoring.

In addition, patients with eating disorders who are medically unstable or have compromised physical health due to malnutrition should be referred immediately to specialist eating disorder services for assessment and management, including refeeding syndrome risk.