Gastroenteric tube feeding: Techniques, problems and solutions

Table 6 Therapy and prevention of refeeding syndrome

Careful evaluation of cardiovascular system, check for any electrolyte abnormalities before initiating refeeding

In severe cases, an initial starting volume of 50%-75% of daily requirements should be used

< 7 yr old: 80-100 kcal/kg bw/d

7-10 yr: 75 kcal/kg bw/d

11-14 yr: 60 kcal/kg bw/d

15-18 yr: 50 kcal/kg bw/d

> 18 yr: 25 kcal/kg bw/d (or an average 1000 kcal/d initially)

If the initial food challenge is tolerated, caloric intake may be increased over the next 3-5 d. Each requirement should be tailored to the individual’s needs, and the above values may need to be adjusted by as much as 30%. Frequent administration of small feeds is recommended. Feeds should provide a minimum of 1 kcal/mL to minimize volume overload

Protein

Initial regimen for malnourished patients: 0.8-1.0 g/kg bw/d

The feed should be rich in essential amino acids, and should gradually be increased, as an intake of 1.2-1.5 g/kg bw/d is needed for anabolism to occur

Vitamins/trace elements

Thiamine, folic acid, riboflavin, ascorbic acid and pyridoxine should be supplemented, as well as the fat-soluble vitamins A, D, E, and K

300 mg thiamine should be given IV at least 30 min. before refeeding is initiated, and should be continued with 100 mg iv for at least 7 d. Later on, oral thiamine can be supplemented as 100 mg tablets

Iron should be supplemented iv according to the Ganzoni formula {iron deficit (mg) = bw (kg) × [(target Hb - actual Hb (g/L )] × 2.4 + depot iron (500 mg)}

Minerals

Sodium should be restricted (about 1 mmol/kg bw/ or 1.5 g/d), but liberal amounts of phosphorus, potassium and magnesium should be given to patients with normal renal function

Magnesium (normal range: 0.8-1.6 mmol/L )

Mild to moderate hypomagnesemia (0.5-0.7 mmol/L )

→Initially 0.5 mmol/kg bw/d over 24 h iv, then 0.25 mmol/kg bw/d for 5 d iv

Maintenance requirement

→0.2 mmol/kg bw per day iv or 0.4 mmol/kg bw per day orally

Phosphate (normal range: 0.85-1.40 mmol/L)

Mild hypophosphatemia (0.6-0.85 mmol/L)

→0.3-0.6 mmol/kg bw per day orally

Moderate hypophosphatemia (0.3-0.6 mmol)

→0.3-0.6 mmol/kg bw per day orally

Severe hypophosphatemia (< 0.3 mmol/L )

iv supplementation with either potassium phosphate or sodium phosphate (e.g., 0.8 mmol/kg bw monobasic potassium phosphate in half-normal saline by continuous infusion over 8-12 h)

Plasma phosphate, calcium, magnesium and potassium should be monitored, and the infusion should be stopped once plasma phosphate concentration exceeds 0.30 mmol/L

Adapted from references[185,191].