Refeeding Syndrome is Not Evident in Failure to Thrive

From the 2019 HVPAA National Conference

Dr. Megan Coe (Virginia Commonwealth University), Dr. Lacey Castellano (Virginia Commonwealth University), Dr. Megan Rook (University of Virginia), Dr. Joshua Reyes (University of Virginia), Dr. Joanne Mendoza (University of Virginia), Mrs. Debbie Cheney (University of Virginia), Mrs. Tiffany Soto (Oregan Health & Sciences University), Dr. Jaren Austen (Oregan Health & Sciences University), Dr. Clifton Lee (Virginia Commonwealth University)


Failure to thrive (FTT) is a common diagnosis among pediatric patients under 2 years of age. FTT can have many etiologies with the vast majority due to poor nutritional intake. Refeeding syndrome has been studied in patients with anorexia nervosa, oncologic conditions, those who are critically ill and so-called “hunger strike” patients. There are no dedicated studies looking at the incidence of refeeding syndrome in otherwise healthy infants and children admitted for FTT.


To determine the incidence of refeeding syndrome in otherwise healthy children under 3 years of age admitted for FTT.


This was a multi-center retrospective chart review of patients aged 36 months or younger admitted to the hospital from January 1, 2011 to December 31, 2016 with a primary admission diagnosis of FTT and meeting at least one of the following definitions: (1) weight below the 2nd percentile for age and sex, (2) weight less than 80% ideal, or (3) rate of weight change causing a decrease of two or more percentile lines on WHO growth curve. Refeeding syndrome was defined as potassium level < 3.0 mmol/L, magnesium level < 1.7 mg/dL, phosphate level < 2.5 mg/dL Exclusion criteria included ICU admission, parenteral nutrition, history of prematurity, G-tube feeds, any chronic medical conditions, or primary admission diagnosis other than FTT.


A total of 174 patients met inclusion criteria. Median age was 6 months. Average percentage of ideal body weight was 80% at time of admission. No laboratory evidence of refeeding syndrome occurred in any of the 174 patients meeting inclusion criteria. Of the 174 included patients, 141 (81%) had lab work done at the time of admission and 68 (39%) had lab work repeated at any time interval after admission. A small percentage (6.4%) of patients experienced an adverse event due to repeat lab draw, the most common of which was the need to repeat lab work for a spurious result or to confirm a result.


Refeeding syndrome is a rare complication in otherwise healthy young infants and children admitted for FTT. Strict exclusion criteria was applied in this research and can be used as a guide to identify patients at low-risk for developing refeeding syndrome. Repeat laboratory studies did not impact clinical outcomes. Instead, a small percentage of patients experienced an adverse event. Given the results from this pilot study, larger studies should be conducted to confirm the safety and feasibility of identifying patients at low risk for refeeding syndrome.

Clinical Implications

This research project provides the foundation for larger studies to continue to identify a patient population within the diagnostic category of Failure to Thrive who are at low risk of developing refeeding syndrome. These patients would not need admission lab work nor screening lab work during any hospitalization for FTT. This would help decrease variability in the care of these patients as well as decrease costs and adverse events inherent in obtaining unnecessary routine lab work.

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