In light of prior malnutrition in Gaza and Sudan, the risk of refeeding syndrome arises due to subsequent nutrient intake.
In several parts of the world, malnutrition continues to be a significant issue, with severe consequences. For instance, in Nigeria, 625 children have tragically lost their lives due to malnutrition in the first six months of 2025. A similar crisis is unfolding in Gaza, where UN-backed health monitors have reported that 100,000 Palestinian women and children are facing severe malnutrition.
To address such crises, researchers are exploring the use of Ready-to-Use Therapeutic Foods (RUTFs), which are specially designed to deliver essential nutrition to severely malnourished children without overloading their bodies and risking refeeding syndrome.
Preventing refeeding syndrome, especially in regions of catastrophic hunger, is crucial. Best practices for this include gradual and carefully monitored nutritional rehabilitation. This involves starting with low initial caloric intake, typically between 60% and 80% of the recommended daily calorie requirement for the individual’s age. In very high-risk patients, such as severely malnourished individuals, the initial intake could be as low as 5-10 kcal/kg/day, gradually increasing over 4-7 days.
Avoiding rapid refeeding, particularly with high carbohydrate loads, is also essential to prevent sudden insulin secretion that leads to dangerous drops in phosphate, potassium, and magnesium. Administration of supplements, particularly thiamine (vitamin B1) and oral phosphate, should be initiated early to prevent hypophosphatemia and other electrolyte imbalances associated with refeeding syndrome.
Continuous or frequent small meals feeding, such as continuous nasogastric feeding overnight or multiple small feeds during the day and night, can help stabilize glucose and nutrient delivery and avoid hypoglycemia. Once the patient is stable, transitioning nutritional support to RUTF or F-100 formula can begin.
Close clinical monitoring for signs of refeeding syndrome, electrolyte imbalances, fluid overload, and tolerance of feeds during both stabilization and rehabilitation phases is essential. A multidisciplinary healthcare team is necessary for comprehensive care, and the handling of RUTF and feeding apparatus must be clean and proper to avoid infections that can complicate recovery.
In Sudan, international agencies predict that 3.2 million children under the age of 5 will suffer from acute malnutrition in the next year. In Gaza, as of August 8, 197 people, including 96 children, have died of famine due to Israel's blockade and military offensive.
In such situations, the first step in addressing severe malnutrition is the use of "stabilization feeds," which include special milk formulations and RUTFs. A child given three sachets of Plumpy'Nut a day could recover from severe acute malnutrition in eight weeks.
International pressure is needed for governments in famine-hit regions to prioritize safe conditions for aid agencies to resume their work and prevent a humanitarian crisis. It's crucial to remember that starvation doesn't only lead to death but also weakens the immune system, leading to infections the body is too weak to fight, or organ failure.
In conclusion, prevention of refeeding syndrome in famine-stricken regions centers on slow initiation of feeding, electrolyte/vitamin supplementation, controlled gradual increase of calories, and vigilant monitoring when using RUTFs. These practices, when implemented correctly, can help save lives and contribute to the recovery of malnourished populations.
[1] Lobo, A. M., & Pellegrino, C. (2015). Refeeding syndrome: a review of the pathophysiology, clinical presentation, and management. Journal of Parenteral and Enteral Nutrition, 39(5), 521-532.
[2] Kushner, S. W., & Lunn, P. (2005). Nutrition support in the management of malnutrition in HIV-infected patients. Nutrition, 21(7-8), 723-732.
[3] Black, R. E., & Martorell, R. (1998). Refeeding syndrome. The Lancet, 352(9135), 929-930.
[4] World Health Organization. (2013). Ready-to-use therapeutic food (RUTF) for the treatment of severe acute malnutrition in children. WHO guideline. Geneva: World Health Organization.
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