Refeeding syndrome risk (NICE CG32 criteria)
Checklist of the NICE CG32 criteria for high risk of refeeding problems, with NICE's suggested starting energy and the supplements it recommends.
Inputs
Optional; works out the starting kcal.
Major: BMI under 16 kg/m²
Major: Unintentional weight loss over 15% in the last 3 to 6 months
Major: Little or no nutritional intake for more than 10 days
Major: Low potassium, phosphate or magnesium before feeding
Minor: BMI under 18.5 kg/m²
Minor: Unintentional weight loss over 10% in the last 3 to 6 months
Minor: Little or no nutritional intake for more than 5 days
Minor: History of alcohol misuse or drugs including insulin, chemotherapy, antacids or diuretics
BMI under 14 kg/m² or negligible intake for more than 15 days
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Worked calculation
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- NICE CG32
When to use
- Before starting oral, enteral or parenteral nutrition in an adult who has eaten little.
Pearls and pitfalls
- NICE: before and during the first 10 days of feeding, give oral thiamin 200 to 300 mg daily, vitamin B co strong 1 to 2 tablets three times a day (or full-dose IV vitamin B) and a balanced multivitamin and trace element supplement once daily.
- NICE: provide potassium (about 2 to 4 mmol/kg/day), phosphate (about 0.3 to 0.6 mmol/kg/day) and magnesium (about 0.2 mmol/kg/day IV, 0.4 mmol/kg/day oral) unless levels are high; monitor fluid balance.
- ASPEN's 2020 consensus uses broader criteria; local protocols may differ.
Why use
The NICE criteria as a checklist, with the starting rate worked out for the patient's weight.
High risk: one or more major criteria, or two or more minor criteria (NICE CG32). Start at most 10 kcal/kg/day (5 kcal/kg/day if BMI under 14 or negligible intake over 15 days)
NICE CG32 criteria for adults. Patients who are not high risk can still develop refeeding problems; monitor electrolytes.