Synopsis
Recognise malnutrition and refeeding risk, choose oral, enteral or parenteral support through a multidisciplinary plan, and verify benefit, tolerance and safety.
- Screen all relevant patients for malnutrition using current weight, recent unintentional loss and acute intake history; repeat screening when clinical state changes.
- Nutrition assessment adds trajectory, intake, swallowing, gastrointestinal function, inflammation, function, social barriers and patient goals to the screening score.
- Use the oral route when safe and sufficient, enteral tube feeding when the gastrointestinal tract works but oral intake is unsafe or inadequate, and parenteral support when it does not.
Reasoning priorities
Apply the organisation’s validated tool with measured or best-supported anthropometry and intake history.
A risk category triggers assessment and action; oedema, amputations and unavailable weights require documented clinical judgment.
Worked reasoning
A 52-year-old, 1.75 m tall and weighing 50 kg (BMI 16.3 kg/m²), has negligible intake for nine days and low baseline phosphate. They have no alcohol dependence, are alert, swallow safely and have a functioning gastrointestinal tract with no features of Wernicke encephalopathy.
- Recognise high refeeding risk before prescribing unrestricted meals or feed, assess ABCDE and fluid status, and escalate to senior, dietetic and pharmacy support.
- Choose supervised oral food plus oral supplements because swallowing and gut function are safe. At the NICE high-risk ceiling, calculate 10 kcal/kg/day × 50 kg = 500 kcal in the first 24 hours, then increase toward assessed full needs over 4–7 days if clinical and biochemical monitoring remains stable.
- Give NICE preventive vitamin support immediately before and during the first 10 feeding days: oral thiamine 200–300 mg daily, vitamin B compound strong 1–2 tablets three times daily and a balanced multivitamin/trace-element supplement once daily; use an appropriate intravenous B-vitamin preparation only when necessary. Low phosphate is supplemented while feeding under pharmacy-supported product and route selection; the NICE likely requirement is 0.3–0.6 mmol/kg/day, calculated here as 15–30 mmol/day. Calculate potassium and magnesium requirements from weight, route, renal function and serial results rather than automatically giving the top of each range.
- Review fluid balance and clinical status at least daily; check glucose once or twice daily until stable, and sodium, potassium, urea, creatinine, magnesium and phosphate daily initially because refeeding risk is present. Slow progression and escalate for oedema, arrhythmia, respiratory deterioration or worsening electrolyte disturbance, and verify delivered intake and function rather than prescribed calories alone.