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Recognize Malnutrition but Avoid Refeeding Syndrome

      To the Editor:
      In their otherwise comprehensive review article on nosocomial malnutrition, Kirkland et al
      • Kirkland L.L.
      • Shaughnessy E.
      Recognition and prevention of nosocomial malnutrition: a review and a call to action!.
      do not mention an important aspect of inpatient nutritional support, namely the risk of refeeding syndrome. This term encompasses the metabolic disturbances and their associated adverse consequences during reinitiation of nutrition in malnourished individuals. Although the clinical manifestations are linked to various electrolyte and vitamin abnormalities, hypophosphatemia is regarded as both a hallmark and a sentinel sign.
      “Modern” refeeding syndrome was traditionally deemed a complication of re-alimentation in patients with underlying psychiatric diseases such as anorexia nervosa, but a broader clinical context has been recognized, and refeeding syndrome is encountered in various patient groups. For instance, in a Dutch cohort of internal medicine patients, sepsis and malignancy conferred the highest risk.
      • Kraaijenbrink B.V.
      • Lambers W.M.
      • Mathus-Vliegen E.M.
      Incidence of refeeding syndrome in internal medicine patients.
      This is in line with our experience involving 4 patients with underlying malignancy, who developed full-blown refeeding syndrome while being refed during the course of their intercurrent illnesses.
      • Windpessl M.
      • Mayrbaeurl B.
      • Baldinger C.
      • et al.
      Refeeding syndrome in oncology: report of four cases.
      Like malnutrition, refeeding syndrome is preventable; the Short Nutritional Assessment Questionnaire had a high negative predictive value for the diagnosis of refeeding syndrome in an observational study.
      • Kraaijenbrink B.V.
      • Lambers W.M.
      • Mathus-Vliegen E.M.
      Incidence of refeeding syndrome in internal medicine patients.
      Additionally, like malnutrition, refeeding syndrome is considered underdiagnosed.
      • Fotheringham J.
      • Jackson K.
      • Kersh R.
      • Gariballa S.E.
      Refeeding syndrome: life-threatening, underdiagnosed, but treatable.
      Therefore, an article about nosocomial malnutrition could serve as a welcome opportunity to raise awareness of refeeding syndrome among physicians involved in nutritional care. I would like to address this shortcoming by directing the interested reader to pertinent national guidelines that provide detailed instructions in terms of diagnosis, prevention, and treatment of this “forgotten syndrome.”
      • National Institute for Health and Care Excellence
      Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition.
      • Irish Society for Clinical Nutrition & Metabolism
      Prevention and treatment of refeeding syndrome in the acute care setting.
      In brief, in at-risk patients nutritional support should be started cautiously and in an anticipatory manner. A recent retrospective study showed a reduction in 6-month mortality risk if low caloric intake (<50% of target) was initiated in patients with early features of refeeding syndrome.

      Olthof L.E., Koekkoek W.A., van Setten C., et al. Impact of caloric intake in critically ill patients with, and without, refeeding syndrome: a retrospective study. Clin Nutr. doi: 10.1016/j.clnu.2017.08.001.

      A call to action to recognize and prevent in-hospital malnutrition is highly appropriate, but a word of caution about the potentially grave sequelae of overzealous alimentation in this vulnerable population is of equal importance.

      References

        • Kirkland L.L.
        • Shaughnessy E.
        Recognition and prevention of nosocomial malnutrition: a review and a call to action!.
        Am J Med. 2017; 130: 1345-1350
        • Kraaijenbrink B.V.
        • Lambers W.M.
        • Mathus-Vliegen E.M.
        Incidence of refeeding syndrome in internal medicine patients.
        Neth J Med. 2016; 74: 116-121
        • Windpessl M.
        • Mayrbaeurl B.
        • Baldinger C.
        • et al.
        Refeeding syndrome in oncology: report of four cases.
        World J Oncol. 2017; 8: 25-29
        • Fotheringham J.
        • Jackson K.
        • Kersh R.
        • Gariballa S.E.
        Refeeding syndrome: life-threatening, underdiagnosed, but treatable.
        QJM. 2005; 98: 318-319
        • National Institute for Health and Care Excellence
        Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition.
        (Clinical guideline [CG32]. Published date: February 2006. Last updated: August 2017; Available at:) (Accessed December 6, 2017)
        • Irish Society for Clinical Nutrition & Metabolism
        Prevention and treatment of refeeding syndrome in the acute care setting.
        (IrSPEN guideline document 1; Available at:) (Accessed December 6, 2017)
      1. Olthof L.E., Koekkoek W.A., van Setten C., et al. Impact of caloric intake in critically ill patients with, and without, refeeding syndrome: a retrospective study. Clin Nutr. doi: 10.1016/j.clnu.2017.08.001.

      Linked Article

      • The Reply
        The American Journal of MedicineVol. 131Issue 6
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          The authors thank Dr Windpessl for the letter referring to our article.1 We agree that recognizing and treating refeeding syndrome are important for any clinician treating at-risk patients. However, our article describes the epidemiology and lack of recognition of malnutrition as overarching concerns. We feel a specific syndrome is beyond the scope of our article.
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