Ask Dr. H: Treatment of 'refeeding syndrome'

Question:

I'm a nursing student who recently cared for a homeless man who developed alcohol withdrawal and something described as "refeeding syndrome." Can you tell me more about that? He was pretty sick.

Answer: A homeless man is the classic setting where you'll come across "refeeding syndrome." It can be seen in anyone who is profoundly malnourished. Anorexia is another setting where it has been seen. It was first seen in World War II concentration-camp victims who died soon after refeeding.

This man was very malnourished, drawing on his own emaciated body for fuel. He had been breaking down muscle and fat for calories. When he was admitted to the hospital, nutritional support was started. Predictably, about four days later, marked electrolyte (especially a plummeting phosphate level) and fluid imbalances occurred. It happened due to a shift from breaking down his own fat/muscle for fuel to breaking down carbohydrates from food he received. There was a sudden increase in insulin levels after refeeding and a dramatic response by the body to try to store this new fuel in the liver and skeletal muscle for energy.

As part of this refeeding, there's a huge production of "ATP" (adenosine triphosphate), the phosphate-rich molecule of energy that every cell uses for fuel. While that sounds good, the problem is that the red blood cells don't get their fair share of phosphate and become fuel-depleted.

Without phosphorus, red blood cells can't function normally to deliver vital oxygen to the body's organs and tissues. Besides severely low blood levels of phosphate, we see low levels of potassium, magnesium, and thiamine (B vitamins). This all leads to organ damage and dysfunction to the heart, brain, lungs, and nervous system. Untreated, refeeding syndrome can cause seizures, coma, and death.

Treatment of refeeding syndrome involves aggressive replacement - especially phosphate, magnesium, thiamine, and potassium. To reduce the risk of this happening, severely malnourished folks should receive only 50 percent to 70 percent of their caloric needs during the first five days.

Q:

What do you think of chamomile tea to help with sleep? I've been drinking a cup or two every night shortly before bedtime to help me relax. I find it a much safer choice than tranquilizers and sleeping pills.

A: It's always better when we can find non-drug options to help with sleep. Chamomile tea, warm milk, melatonin, and soothing music/sounds are natural remedies that help those who have minimal trouble falling asleep. They're safe, gentle, and free of any addiction potential.

Unfortunately, there are many people who do require a prescription sleep medication when milder treatments fail for reasons such as depression, anxiety, situational stress, or a chronic pain condition.

Chamomile tea has been described for years as a relaxing, noncaffeinated herbal tea. I'm happy that you find it beneficial. It may surprise you to learn that there have been no human studies to date that can verify the anecdotal claims made by chamomile tea drinkers like yourself. There is no evidence that the herb possesses any bioactive properties that can induce calm. There is, however, test-tube evidence that chamomile has some bacteria-killing properties and some effect on platelet clumping. This has not yet been demonstrated in a human study, but bears further investigation.

One last point: Never consume alcohol in the evening to help with sleep.

While it has an initial sedating effect, when the liver metabolizes the alcohol a few hours later, a rebound excitatory effect will make insomnia much worse.