LAUSR

The authors are grateful for Prof. Schuetz, Drs Zurfluh and Stanga’s interest in our work [1], particularly with regard to the interpretation of our clinical data. We are in agreeance regarding the fact that physicians will only document refeeding syndrome (RFS) if they recognize the syndrome. In fact, this was documented in our discussion, “While the criteria used to identify RFS risk appear to lack specificity, there is also the potential that death from RFS may be understated if medical clinicians are not aware of the condition, possibly reducing our identification rate [2–4]. A knowledge deficit concerning RFS has been observed among UK medical practitioners, although no studies have been conducted within Australia [5].” Additionally, “only five patients could be located among ~260,000 deaths, so results may not be generalizable to other health care systems.” However, it is also important to note that these deaths did occur after the existence of RFS became better known in both the literature and in clinical environments. While the authors agree that recommendations should be followed regarding step-wise increases in energy and fluid goals, further research regarding the statement “a careful start of nutritional therapy” is needed. The guidelines that this recommendation originated from were made based on low-level evidence (narrative reviews) and advice of experts in the field [6]. Current literature examining incidence of RFS in patients with anorexia nervosa has found that initiating feeding at a higher energy rate than previously recommended, results in no increased rates of adverse outcomes [7–9]. While we acknowledge differing results in the Doig et al. randomized control trial [10], additional research is warranted in other population groups frequently recognized to be at risk of RFS in order to evaluate these recommendations. Finally, the cited meta-analysis found no associations between death and RFS or hypophosphatemia [11]. The authors believe that these results are similar to the current study’s findings [12].