Comparison of feeding protocols for prevention of RS
| NICE (2006) [2] | ASPEN (2020) [3] | |
|---|---|---|
| Initiation of calories & feeding advancement | Starting nutrition support at a maximum of 10 kcal/kg/day, increasing levels slowly to meet or exceed full needs by 4–7 days, using only 5 kcal/kg/day in extreme cases (e.g., BMI<14 kg/m2 or negligible intake for more than 15 days) | Initiate 100–150 g of dextrose or 10–20 kcal/kg for the first 24 hours; advance by 33% of goal every 1–2 day(s) In patients with moderate to high risk with low electrolyte levels, holding the initiation of or increase in calories until electrolytes are supplemented should be considered Initiation of or increase in calories should be delayed in patients with severely low phosphorus, potassium, or magnesium levels until corrected |
| Electrolytes & thiamine | Provided immediately before and during the first 10 days of feeding: oral thiamin 200–300 mg daily, vitamin B co strong 1–2 tablet(s), three times a day (or full dose given daily as intravenous vitamin B preparation, if necessary), and a balanced multivitamin/trace element supplement once daily Provide oral, enteral, or intravenous supplements of potassium (likely requirement 2–4 mmol/kg/day), phosphate (likely requirement 0.3–0.6 mmol/kg/day), and magnesium (likely requirement 0.2 mmol/kg/day intravenously, 0.4 mmol/kg/day orally) unless prefeeding plasma levels are high. Prefeeding correction of low plasma levels is unnecessary |
Monitor every 12 hours for the first 3 days in high-risk patients (more frequent based on the clinical picture) Give thiamine 2 mg/kg to a maximum of 100–200 mg/day before feeding commences or before initiating intravenous fluids containing dextrose in high-risk patients Replete low electrolytes based on established standards of care Continue thiamine supplementation for ≥5–7 days in patients with severe starvation, chronic alcoholism, or at high risk for other deficiency and/or signs of thiamine deficiency |
| Other recommendations | Calories from intravenous dextrose solutions and medications being infused in dextrose should be considered in patients at moderate to severe risk for RS If electrolytes become difficult to correct or drop precipitously during the initiation of nutrition, decrease calories/grams of dextrose by 50% and advance the dextrose/calories by approximately 33% of the goal every 1–2 day(s) based on clinical presentation |
RS = refeeding syndrome; NICE = National Institute for Health and Care Excellence; ASPEN = American Society of Parenteral and Enteral Nutrition; BMI = body mass index.