Re-feeding syndrome and dysphagia

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

1. During starvation fat and protein are catabolised.
2. When the body shifts back to carbohydrate metabolism insulin is secreted again, which stimulated cellular uptake of phosphate and causes low serum phosphate levels.
3. Phosphate is required for ATP production (ATP transports chemical energy within cells).
4. 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.