Re- feeding syndrome
Introduction
- I've recently had a patient who had pharyngeal dysphagia and re-feeding syndrome. I was trialling oral intake with the patient using yogurt and water. A few days after admission the patients swallow deteriorated further due to re-feeding syndrome and then improved.
- The consultant doctor reported that low phosphate, magnesium and potassium caused by re-feeding syndrome affects neuo-muscular function and therefore swallowing.
- Global atrophy caused by nutrition may also cause weak swallow musculature.
History
- First described in prisoners of war when they started to eat again after prolonged starvation.
- Eating again appeared to precipitate cardiac failure.
Mechanism
- During starvation fat and protein are catabolised.
- When the body shifts back to carbohydrate metabolism insulin is secreted again, which stimulated cellular uptake of phosphate and causes low serum phosphate levels.
- Phosphate is required for ATP production (ATP transports chemical energy within cells).
- Hypertension, arrhythmia's, electrolyte depletion (Mg is used in nerve and muscle cells, K is used in neuromuscular junctions), hyperglycaemia and dysfunction of various organ systems e.g. Cardiovascular, musculoskeletal, neurologic and immune systems.
Relevance to stroke patients
- Patients with neurological dysphagia fed via a PEG or NG-feed are at risk of re-feeding syndrome.
- Serum phosphste levels below 0.50 mmol/l = re-feeding syndrome.
- When patients have re-feeding syndrome their swallow function is likely to be affected: Weaker pharyngeal muscle contractions, reduced swallow coordination and oral stage muscular impairments may be observed.
- Patients with re-feeding syndrome are likely to have their swallow improve once they are treated.
- Intravenous phosphate is used to treat re-feeding syndrome.
References:
Hearing, SD (2004) Re-feeding syndrome, BMJ, 328(7445), 908-909.
Marinella, MD (2004) Re-feeding syndrome: Implications for the inpatient rehabilitation unit, American Journal of Rehabilitation, 83:65-68.