How to feed a malnourished person: a complete guide

The World Health Organization reports that nearly half of deaths among children under 5 years of age are linked to undernutrition. Properly feeding a malnourished person is a critical intervention that must be approached with caution and careful planning to ensure a safe and successful recovery without causing life-threatening complications.

Quick Summary

Managing malnutrition involves a careful, phased feeding approach, starting with a clinical assessment to mitigate the high risk of refeeding syndrome. Nutrient-dense foods, frequent small meals, and electrolyte monitoring are essential, with the potential need for nutritional supplements.

Key Points

• Start slowly: Begin refeeding with low calories and small, frequent meals to prevent refeeding syndrome.

• Fortify foods: Add extra calories and protein to meals with ingredients like butter, oil, and skimmed milk powder.

• Supplement strategically: Use oral supplements or feeding tubes when diet alone is insufficient.

• Monitor electrolytes: Closely track potassium, phosphate, and magnesium levels to prevent life-threatening shifts.

• Consult professionals: Always involve a doctor or dietitian, especially with severe malnutrition, to create a safe feeding plan.

• Provide vitamins: Supplementation with thiamine and other vitamins is crucial before starting and during refeeding.

What is Malnutrition and Why is Feeding Cautious?

Malnutrition is a serious condition resulting from a deficiency, excess, or imbalance of energy and nutrients. The most critical form, undernutrition, is characterized by insufficient calorie and protein intake, leading to significant weight loss and muscle wasting. The goal of nutritional support is to gradually and safely restore the individual's nutritional status. The feeding process is not as simple as immediately providing large amounts of food. In severely malnourished individuals, a sudden increase in nutrition, especially carbohydrates, can trigger a dangerous condition known as refeeding syndrome. Therefore, a structured, medically supervised plan is essential to prevent complications and ensure a successful recovery.

Understanding the Dangers of Refeeding Syndrome

Refeeding syndrome (RFS) is a potentially fatal shift in fluids and electrolytes that can occur when a severely malnourished person is fed too aggressively. During starvation, the body's metabolism slows down and shifts away from carbohydrates, conserving key minerals. When refeeding begins, particularly with carbohydrates, insulin levels rise sharply. This triggers the cellular uptake of glucose, along with key electrolytes like phosphate, potassium, and magnesium. The rapid movement of these electrolytes from the blood into the cells can cause critically low serum levels (hypophosphatemia, hypokalemia, hypomagnesemia), leading to severe complications.

Key Risks and Symptoms

• Cardiac issues: Arrhythmias, heart failure.
• Fluid imbalances: Oedema (swelling), especially pulmonary oedema.
• Neurological problems: Confusion, seizures, delirium.
• Thiamine deficiency: Wernicke-Korsakoff syndrome, which can cause neuropathy.

To prevent RFS, healthcare professionals must identify at-risk patients and initiate nutritional support cautiously. Supplementing with vitamins, especially thiamine, before feeding and monitoring electrolytes are crucial preventive measures.

A Phased Approach to Nutritional Rehabilitation

Feeding a malnourished person typically follows a gradual, multi-phase process to ensure safety and effectiveness.

Phase 1: Initial Stabilization

This phase focuses on correcting fluid and electrolyte imbalances and slowly reintroducing nutrition. This may take several days, depending on the severity of malnutrition.

• Start with a low-calorie, low-carbohydrate intake, sometimes as low as 5-10 kcal/kg/day.
• Provide small, frequent meals or feeds (6-10 times daily) to prevent overwhelming the body.
• Administer vitamin and mineral supplements, especially thiamine, before and during the first week of feeding.
• Monitor blood electrolyte levels (potassium, phosphate, magnesium) multiple times daily.
• Treat underlying infections, which are common in malnourished individuals.

Phase 2: Gradual Rehabilitation

Once the patient is stable, calories can be increased incrementally. The goal is to reach full nutritional requirements without triggering RFS.

• Increase calories gradually, sometimes by 10-20% daily.
• Use nutrient-dense, fortified foods to maximize caloric and protein intake without increasing meal volume.
• Continue close monitoring of electrolytes, fluid balance, and clinical status.

Phase 3: Catch-up Growth and Long-term Recovery

The final phase focuses on promoting rapid weight gain and addressing any remaining nutritional deficiencies.

• Provide higher energy and protein diets, aiming for 100-200 kcal/kg/day for children or higher requirements for adults.
• Introduce iron supplementation, but only after appetite has returned and the person is gaining weight, to avoid exacerbating infections.
• Educate caregivers on long-term dietary needs to prevent relapse.

Strategies for Increasing Caloric and Nutrient Intake

For individuals who can eat, fortifying foods and using high-calorie options are effective.

Food Fortification Techniques

A list of simple ways to increase the energy density of food includes:

• Adding fats: Stir butter, margarine, or oil into mashed potatoes, soups, or pasta.
• Using dairy products: Add cream to sauces, soups, and porridge. Grate cheese over vegetables, pasta, or eggs.
• Mixing in powders: Whisk skimmed milk powder into whole milk for a higher protein, higher calorie fortified milk. Ground nuts or nut butter can also be mixed into stews or porridges.

Comparison of Fortified vs. Unfortified Milk

This table demonstrates how simple fortification can drastically increase the nutritional value of a staple food.

Feature	Unfortified Whole Milk	Fortified Whole Milk
Calories	~150 kcal per pint	~250 kcal per pint
Protein	~18g per pint	~30g per pint (with added skimmed milk powder)
Benefits	Good source of calcium	Enhanced energy and protein for rapid recovery
Preparation	Ready to drink	Requires whisking in powder

Role of Nutritional Supplements

For those who cannot meet their nutritional needs through diet alone, supplements are essential.

• Oral Nutritional Supplements (ONS): These come in liquid or powder form and provide concentrated carbohydrates, protein, fats, and micronutrients. They can be used as snacks or meal replacements and are available in various flavors and consistencies.
• Enteral Feeding: Tube feeding (via nasogastric or gastrostomy tube) is used when a patient cannot consume enough orally but has a functioning gastrointestinal tract.
• Parenteral Nutrition (PN): This involves delivering nutrients directly into the bloodstream intravenously, bypassing the digestive system entirely. It is reserved for severe cases where the gut is not functional.

Conclusion

Feeding a malnourished person requires a cautious, phased approach that prioritizes safety, especially due to the risk of refeeding syndrome. Starting with small, frequent, nutrient-dense meals and gradually increasing intake while carefully monitoring electrolyte levels is the cornerstone of effective rehabilitation. The use of fortified foods and, if necessary, oral or tube-fed nutritional supplements plays a vital role. A multidisciplinary team, including dietitians and medical professionals, is crucial for guiding this complex process and ensuring a successful, long-term recovery for the individual. The overall goal is not just to provide calories but to rebuild the body's strength and health with proper nutrition.

For more information on the global impact of malnutrition, consult resources like the World Health Organization: https://www.who.int/news-room/fact-sheets/detail/malnutrition.

Frequently Asked Questions

What is refeeding syndrome?

Refeeding syndrome is a dangerous metabolic and electrolyte disturbance caused by a rapid shift from a starvation-induced state to a fed state. It can cause heart failure, respiratory problems, and neurological issues.

How often should a malnourished person eat?

Small, frequent meals, typically 6 to 10 per day, are recommended to prevent overwhelming the digestive system and to help overcome a poor appetite.

What are good foods to offer?

Focus on nutrient-dense foods that are easy to digest, such as fortified milk, scrambled eggs with cheese, milky puddings, soups with added cream or butter, and high-protein oral supplements.

Is it safe to give iron supplements right away?

No, iron supplementation should typically be delayed until the patient has a good appetite and begins gaining weight, as early iron administration can worsen infections.

What should I do if a malnourished person refuses food?

Try offering smaller amounts of their favourite foods frequently. If refusal persists, a healthcare professional may recommend alternative nutritional support, such as oral nutritional supplements or tube feeding.

What are fortified foods?

Fortified foods are meals that have been enhanced with extra calories and nutrients, for instance, adding butter, oil, grated cheese, or milk powder to increase their energy and protein content.

When is it necessary to see a doctor or dietitian?

Professional help is always recommended for managing malnutrition. Immediate medical attention is vital if the person is severely underweight, has prolonged poor intake, or shows signs of fluid retention (oedema).