Report: From Malnutrition to Medical Emergency—The Hidden Crisis of Refeeding Syndrome in Gaza

25 April, 2025

After months of unrelenting siege, mass displacement, and the systematic obstruction of humanitarian corridors, Gaza’s civilian population—especially its children—is facing catastrophic levels of starvation. The limited entry of humanitarian aid in recent weeks, though critically needed, arrives into a physiological environment shaped by severe nutritional deprivation, multiorgan stress, and metabolic downregulation. In this context, one of the gravest and least understood threats to life is emerging not from continued starvation, but from the act of feeding itself.

Refeeding Syndrome (RFS) is a well-documented, potentially fatal clinical condition that occurs when nutrition—particularly carbohydrates—is reintroduced after prolonged periods of undernutrition or fasting. This reintroduction triggers a surge in insulin secretion, shifting electrolytes such as phosphate, potassium, and magnesium from the bloodstream into cells. In individuals with severely depleted reserves, this shift can precipitate acute cardiac failure, respiratory dysfunction, rhabdomyolysis, seizures, and irreversible neurological impairment. Paediatric patients are particularly vulnerable, as their smaller physiological buffers and ongoing developmental needs heighten susceptibility.

Despite its well-established pathophysiology and high mortality rate if left untreated, Refeeding Syndrome remains under-recognised in field-based humanitarian settings. This oversight is especially dangerous in Gaza, where hundreds of thousands of children will enter refeeding phases without access to structured nutritional protocols, biochemical monitoring, or appropriate clinical supervision.

This report presents an urgent clinical and humanitarian briefing on Refeeding Syndrome in the context of Gaza. It synthesises current medical literature, field assessments, and historical insights from other famine-affected regions to outline the risk factors, clinical presentation, diagnostic criteria, and evidence-based prevention strategies for RFS. It also offers actionable recommendations for healthcare providers, NGOs, and policymakers tasked with delivering nutritional support to populations recovering from starvation.

As aid deliveries gradually resume, the international community must not overlook the life-threatening physiological fragility of those they seek to nourish. Without immediate implementation of context-specific, medically informed refeeding protocols, thousands of Gaza’s children face a second wave of preventable mortality: one not from hunger, but from the very food intended to sustain life.

Pathophysiology of Refeeding Syndrome 

During prolonged starvation, the human body undergoes a series of adaptive but ultimately depleting metabolic changes designed to preserve life in the face of energy scarcity. With the absence of carbohydrate intake, insulin secretion sharply declines, and the body transitions into a catabolic state—mobilising fat and protein as alternative energy sources. While this metabolic shift maintains short-term survival, it carries significant physiological costs.

Over time, intracellular stores of critical electrolytes—phosphate, magnesium, and potassium—become profoundly depleted, even as serum levels may appear deceptively normal. Basal metabolic rate slows, lean body mass diminishes, and cardiac and gastrointestinal musculature begin to atrophy. Thiamine (Vitamin B1), an essential cofactor in carbohydrate metabolism and neural function, is gradually exhausted. These adaptations leave the body in a precarious state of biochemical fragility.

When food is reintroduced—especially carbohydrate-rich staples like bread, rice, or sugar—insulin secretion rapidly resumes. This hormonal surge facilitates the intracellular uptake of glucose and, critically, the concurrent cellular shift of phosphate, potassium, and magnesium. The result is a precipitous drop in serum concentrations of these electrolytes, triggering a cascade of potentially fatal complications.

Hypophosphatemia, by impairing adenosine triphosphate (ATP) production, can lead to cardiac arrhythmias, impaired diaphragmatic contractility, haemolysis, and seizures. Concurrent hypokalaemia and hypomagnesemia further destabilise cardiac conduction, dramatically increasing the risk of sudden cardiac arrest. Thiamine deficiency, if uncorrected, may precipitate Wernicke’s encephalopathy, peripheral neuropathy, or lactic acidosis due to impaired oxidative metabolism.

In essence, refeeding syndrome represents a lethal paradox: a malnourished body, already weakened by famine, begins to fail not from the absence of food, but from its sudden return—unless careful metabolic and electrolyte management is in place.

Vulnerable Populations in Gaza

Refeeding Syndrome in Gaza is no longer a theoretical concern—it is an emerging clinical crisis unfolding in real time. As food supplies trickle into a population ravaged by prolonged siege, forced displacement, and deliberate obstruction of aid, the very act of eating poses a new and under-recognised danger. The populations most at risk of developing Refeeding Syndrome are those whose physiological reserves are already critically depleted, and whose ability to compensate for sudden metabolic shifts is severely impaired.

Among the most vulnerable are infants and young children under the age of five, particularly those exhibiting clinical signs of acute malnutrition, including visible wasting consistent with marasmus or oedematous malnutrition indicative of kwashiorkor. These children have minimal intracellular stores of phosphate and potassium, rendering them especially susceptible to hypophosphatemia, cardiac arrhythmias, and neuromuscular collapse when carbohydrates are reintroduced without prior correction of electrolyte and micronutrient deficiencies. Their underdeveloped organs, already weakened by malnutrition, are ill-equipped to withstand the abrupt metabolic demands of refeeding.

Pregnant and lactating women also face compounded risk. The physiological demands of pregnancy and breastfeeding significantly increase caloric and micronutrient requirements, yet many of these women have endured months of dietary insufficiency. As food becomes accessible, the impulse to “eat for two” may lead to unregulated caloric intake in the absence of thiamine, magnesium, or phosphate supplementation, triggering RFS in a context where medical oversight is absent. The consequences extend beyond maternal health, posing risks to foetal development and neonatal outcomes.

Patients requiring hospital-based care—particularly those who are unconscious, mechanically ventilated, or receiving enteral or parenteral nutrition—represent another high-risk category. These individuals often rely on external feeding strategies to survive, yet in Gaza’s devastated health system, the ability to monitor electrolytes, initiate gradual refeeding, or provide prophylactic micronutrients is nearly non-existent. The result is a highly volatile clinical picture where RFS can manifest rapidly and lethally, often without warning.

Those living with chronic diseases such as cancer, chronic kidney disease, or poorly controlled diabetes are at elevated risk due to baseline metabolic fragility. These conditions are widespread in Gaza, where access to continuity of care, dialysis, chemotherapy, or insulin has been severely disrupted. Malnutrition further complicates their clinical stability, and any sudden nutritional intake without biochemical management may tip the balance into life-threatening decompensation.

A 2021 review by Médecins Sans Frontières on famine responses in East Africa reported that up to 27% of severely malnourished individuals developed complications associated with Refeeding Syndrome when food aid was administered without appropriate safeguards. In Gaza, where famine is now widespread, clinical monitoring is nearly impossible, and starvation is weaponised, the prevalence of RFS is likely to be even higher,albeit undiagnosed and undocumented.

This report seeks not only to highlight the populations at highest risk, but to sound the alarm: without targeted nutritional strategies and urgent international mobilisation of clinical expertise, the reintroduction of food—absent a medically informed framework—may result in preventable deaths across the very groups this aid is meant to protect.

Clinical Manifestations in Field Settings

Refeeding Syndrome (RFS) presents with a spectrum of acute, life-threatening complications that may appear rapidly once nutrition is reintroduced. In field settings such as Gaza—where laboratory diagnostics, intensive monitoring, and critical care infrastructure are effectively absent—these clinical signs often go unrecognised, misattributed, or underreported. Yet their physiological basis is clear, and their consequences devastating.

Cardiopulmonary Complications

The cardiovascular system is one of the first to decompensate in RFS. A sudden intracellular shift of phosphate, potassium, and magnesium following renewed insulin secretion can precipitate:

  • Fatal arrhythmias, including ventricular tachycardia or fibrillation, triggered by hypokalemia and hypomagnesemia.

  • Congestive heart failure, as the weakened, atrophied myocardium is overwhelmed by increased intravascular volume from rehydration and nutritional repletion.

  • Hypotension and bradycardia, particularly in paediatric patients, where autonomic instability compounds the risk of circulatory collapse.

These events can occur with little warning, particularly in children whose myocardial tissue is already compromised by protein-energy malnutrition.

Neurological Signs

Neurological complications are frequently underdiagnosed, yet represent a major cause of morbidity and mortality:

  • Seizures are often the first neurological sign, secondary to profound hypophosphatemia or hypomagnesemia.

  • Confusion, delirium, ataxia, and coma may result from acute thiamine deficiency, which impairs cerebral glucose utilisation. This can progress to Wernicke’s encephalopathy, a potentially irreversible neurodegenerative condition.

  • In severe and prolonged cases, peripheral neuropathy, limb weakness, or even flaccid paralysis can occur due to prolonged electrolyte depletion.

In field contexts, these symptoms may be misinterpreted as sepsis, meningitis, or severe dehydration, masking the underlying iatrogenic nature of the crisis.

Respiratory Failure

Respiratory compromise is another critical, yet often overlooked, manifestation of RFS:

  • Diaphragmatic and intercostal muscle weakness from hypophosphatemia can lead to shallow breathing, inadequate ventilation, and reduced oxygen saturation.

  • The sudden increase in metabolic demand following refeeding places significant strain on malnourished lungs and respiratory musculature, often unprepared for the increased workload.

  • In infants and young children, respiratory arrest can occur rapidly, particularly in those with coexisting pneumonia, bronchiolitis, or structural lung damage from previous illness.

Without access to mechanical ventilation or intensive care, these cases are frequently fatal.

Gastrointestinal Effects

The gastrointestinal system, often compromised by atrophy and prolonged disuse, responds poorly to abrupt refeeding:

  • Nausea, vomiting, abdominal distension, and paralytic ileus are common in the early phase of refeeding, often misattributed to infectious gastroenteritis or “refusal to eat.”

  • Hepatic dysfunction, including fatty liver infiltration, may occur as the liver struggles to process the sudden influx of glucose and lipids.

  • In cases of extreme mucosal atrophy and compromised gut integrity, there is a theoretical but serious risk of intestinal perforation, particularly in children with kwashiorkor.

Field Realities: Misdiagnosis and Missed Opportunities

In the context of Gaza’s ongoing humanitarian catastrophe, the clinical detection and management of Refeeding Syndrome (RFS) is critically hampered by the near-total collapse of diagnostic infrastructure. Basic laboratory assays—such as serum phosphate, potassium, magnesium, and thiamine levels—are either unavailable or severely limited in both quantity and geographic reach. This diagnostic vacuum renders the early identification of RFS not merely challenging but, in most cases, clinically unattainable.

In such austere environments, frontline clinicians and humanitarian responders often rely on syndromic observation. However, the cardinal signs of RFS—bradycardia, lethargy, muscle weakness, seizures, or altered consciousness—are easily conflated with the broader clinical spectrum of malnutrition, dehydration, infectious disease, or trauma. In infants, for example, the onset of respiratory failure or seizures may be misattributed to underlying neurological conditions or sepsis, rather than the sudden electrolyte imbalances triggered by refeeding. Similarly, gastrointestinal stasis or cardiac arrhythmia in an emaciated child may be viewed as inevitable consequences of starvation rather than correctable complications of premature or unregulated nutritional support.

This diagnostic ambiguity fosters a dangerous cycle: iatrogenic harm remains unrecognised, appropriate adjustments to feeding regimens are not made, and mortality mounts even after food aid begins to arrive. The very act of feeding—intended as a life-saving intervention—thus becomes, in the absence of training and clinical oversight, a precipitating factor in further physiological decline.

Moreover, the systemic lack of protocols, risk stratification tools, and clinical algorithms for RFS within humanitarian response frameworks compounds the danger. Health workers, already stretched beyond capacity, are rarely equipped with the resources or decision-making support required to modulate refeeding rates, administer micronutrient supplementation pre-emptively, or triage patients based on metabolic risk. The result is an over-reliance on uniform food distribution rather than patient-specific therapeutic nutrition—a misalignment that can prove fatal for the most vulnerable.

As international aid operations slowly expand in Gaza, a narrow clinical window exists to mitigate the secondary wave of refeeding-related deaths. This will require urgent investment in capacity-building:

Operational Gaps in Gaza’s Aid Response

The current humanitarian response lacks the medically informed infrastructure necessary to prevent secondary mortality from Refeeding Syndrome (RFS). This gap—rooted in the absence of controlled nutritional protocols, electrolyte surveillance, and micronutrient availability—threatens to undermine the very purpose of emergency feeding operations. As a result, well-intentioned efforts to combat famine risk triggering a wave of preventable, iatrogenic deaths, particularly among the most vulnerable.

Absence of Controlled Nutritional Protocols

In established clinical and emergency nutrition settings, the World Health Organization (WHO) and UNICEF mandate phased, closely monitored refeeding protocols for individuals with Severe Acute Malnutrition (SAM). These include the use of therapeutic milks such as F-75 (low-protein, low-sodium) and F-100 (higher calorie), administered under strict clinical supervision and supported by serial assessments of weight gain, hydration status, and biochemical stability.

In Gaza, these protocols are virtually non-existent. The collapse of the healthcare system, combined with the fragmentation of humanitarian coordination, has left the burden of food distribution largely in the hands of untrained volunteers, overstretched civil society actors, and informal community groups operating under siege conditions. In such environments, there is widespread lack of awareness regarding the metabolic dangers posed by unregulated refeeding. Key risks include:

  • High-sugar foods—such as dates, biscuits, and sweetened juices—triggering abrupt insulin spikes and electrolyte shifts in starved individuals.

  • Therapeutic foods, including Plumpy’Nut and other ready-to-use therapeutic foods (RUTFs), being distributed without dose regulation or prior micronutrient repletion in high-risk children.

  • Rehydration formulas not adapted for SAM, often containing excessive sodium, thereby compounding the risk of fluid overload and cardiac failure in patients with compromised renal and myocardial function.

Without formalised clinical guidelines or phased implementation strategies, Gaza’s refeeding landscape remains dangerously unregulated.

Electrolyte Monitoring and Diagnostic Blind Spots

One of the most critical components of RFS prevention is the ability to measure and track serum concentrations of phosphate, potassium, magnesium, and thiamine. These values guide the identification of high-risk patients and inform electrolyte supplementation protocols.

However, in Gaza, the widespread destruction of medical facilities, shortages of reagents, and power outages have rendered even the most basic laboratory services non-functional. Field medics, operating in improvised clinics or mobile units, are forced to work without access to point-of-care testing or reliable diagnostic support. As a result, at-risk individuals—particularly children with marasmus or kwashiorkor—are being reintroduced to food while metabolically unprepared, precipitating a cascade of potentially fatal complications.

Critical Shortages of Micronutrient Support

Effective prevention and treatment of RFS requires not only controlled caloric reintroduction but also aggressive pre-emptive supplementation. International guidelines recommend that individuals at risk receive:

  • Thiamine (Vitamin B1) prior to the reintroduction of carbohydrates, to support mitochondrial glucose metabolism and prevent acute lactic acidosis or Wernicke’s encephalopathy.

  • Oral or intravenous phosphate, essential for ATP production and neuromuscular stability.

  • Potassium and magnesium, to stabilise cardiac rhythms and reduce the risk of respiratory arrest.

In Gaza, these micronutrients are in critically short supply. Anecdotal field reports suggest that most humanitarian food deliveries do not include refeeding-safe supplements, and emergency medical shipments prioritise antibiotics and trauma care supplies over essential electrolytes and vitamins. This imbalance reflects a broader failure to integrate nutritional science into crisis logistics.

To address this shortfall, all future aid shipments must be structured around refeeding-safe bundles that include therapeutic foods and the accompanying medical interventions required for their safe administration. Anything less risks converting a food crisis into a metabolic emergency.

The Gaza-Specific Context

The clinical threat posed by Refeeding Syndrome (RFS) in Gaza must be understood within the context of a uniquely devastated healthcare and humanitarian environment. While the pathophysiology of RFS is well-documented, Gaza presents an extreme convergence of risk factors: a collapsed medical infrastructure, a displaced and traumatised population, and the absence of clinical capacity to detect or manage complications. These contextual variables not only exacerbate the risk of RFS but render standard treatment protocols functionally inapplicable.

Severe Shortage of Paediatric and Nutrition Expertise

One of the most significant clinical barriers in Gaza is the lack of specialised paediatric and nutritional medicine expertise. The majority of medical professionals who remain in the Strip are generalists, surgeons, or emergency physicians responding to trauma and mass casualty events. Nutritionists, clinical dietitians, and paediatricians with training in refeeding protocols are either absent, overwhelmed, or cut off from frontline care delivery.

This gap means that malnourished children—particularly those with severe acute malnutrition (SAM)—are frequently reintroduced to food without a structured risk assessment, staged nutritional plan, or clinical oversight. In the absence of such expertise, critical early signs of RFS may go unnoticed or be misattributed to baseline malnutrition, infection, or sepsis.

Infrastructure Collapse and Inaccessibility of Clinical Refeeding

Even when RFS is suspected or recognised, Gaza’s decimated healthcare system is unable to provide the supportive environment necessary for safe, gradual refeeding. Key components of standard care—such as controlled fluid intake, warm and sterile settings, and continuous monitoring of weight, electrolyte status, and urine output—are simply unavailable. Hospitals lack:

  • Functional beds, with entire wards destroyed or repurposed for trauma care.

  • Reliable electricity, undermining neonatal and paediatric life support.

  • Sterile preparation facilities, risking infection from therapeutic feeding formulas.

In such an environment, the idea of admitting a severely malnourished child for inpatient nutritional rehabilitation is no longer feasible. Families are forced to initiate refeeding in tents, makeshift shelters, or partially collapsed buildings—without the clinical scaffolding required to mitigate the metabolic dangers that follow.

Psychosocial Trauma and the Risk of Overfeeding

Psychological trauma is another critical and under-acknowledged factor shaping Gaza’s refeeding landscape. Parents and caregivers, having watched their children endure extreme hunger and wasting, may respond with instinctive overfeeding once food becomes available. This well-meaning response, driven by desperation and grief, can be metabolically catastrophic.

Without counselling or public health messaging on the risks of RFS, caregivers may administer calorie-dense meals or high-sugar snacks in amounts the child’s body cannot physiologically process. In many cases, this can result in sudden decompensation and death—misinterpreted as the child being “too far gone,” rather than an avoidable outcome of uncontrolled refeeding.

Displacement, Instability, and the Impossibility of Follow-Up

Finally, the high mobility of Gaza’s displaced population poses a direct challenge to clinical follow-up. With families constantly moving to escape bombardment, tracking a malnourished child’s progress after food reintroduction is virtually impossible. There is no continuity of care, no ability to monitor vital signs, and no pathway for escalation should complications arise.

Community health workers, where they exist, lack the logistical capacity to follow mobile populations. In many cases, children begin refeeding in one location and deteriorate in another—with no documentation, case history, or access to medical review. This breakdown in continuity turns a manageable clinical condition into a silent killer, spreading through a population already devastated by war and famine.

A Call to Action: The Urgent Need for International Intervention

The unfolding nutritional catastrophe in Gaza presents not only a humanitarian crisis but also a highly specific medical emergency: the widespread and largely unrecognised risk of Refeeding Syndrome (RFS), a preventable iatrogenic complication. In a population suffering from prolonged caloric deprivation, the sudden reintroduction of food—if not medically managed—can precipitate fatal metabolic collapse. Preventing deaths from RFS is not a matter of advanced care, but of deploying basic, evidence-based protocols at scale.

Failure to integrate refeeding safety into aid delivery risks transforming food relief into a vector of unintended harm. A coordinated, medically informed response is urgently needed, and the international community must act with both speed and precision.

Integrate Refeeding Protocols into All Humanitarian Food Aid

Food distribution, particularly in famine-affected populations, cannot be approached as a standalone act of relief. All incoming aid—whether via NGOs, UN agencies, or civilian convoys—must be accompanied by evidence-based refeeding protocols adapted from WHO and UNICEF guidelines. These protocols must be translated into accessible formats including printed infographics, pictorial instructions, and audio messaging in Arabic dialects spoken across Gaza. Messaging should emphasise:

  • Phased reintroduction of calories, beginning with low-energy-density foods (such as F-75) where possible.

  • Avoidance of high-sugar items, including biscuits, dates, and fruit juices, which can precipitate insulin spikes and electrolyte shifts.

  • Printed visual aids and audio instructions in Arabic, explaining early warning signs and appropriate feeding quantities, especially targeted at caregivers.

Elevate Electrolytes and Micronutrients to Critical Aid Priority

RFS is not a nutritional problem alone—it is a metabolic emergency. Its prevention depends not on calories, but on the availability of specific biochemical substrates: phosphate, potassium, magnesium, and thiamine. These should be categorised as emergency medical supplies on par with trauma kits, antibiotics, and intravenous fluids. Electrolyte repletion is the cornerstone of RFS prevention. Current aid shipments must urgently prioritise these supplements as co-equal to food in all humanitarian supply chains, not as ancillary:

  • Oral and intravenous phosphate, magnesium, and potassium preparations.

  • High-dose thiamine, to be administered before carbohydrate intake resumes.

  • Low-osmolar rehydration salts, to avoid sodium overload in fluid-depleted children.

Deploy Mobile Nutritional Stabilisation Units

In the absence of hospital infrastructure, the international community must fund and field Mobile Nutritional Stabilisation Units. These units should be embedded within existing humanitarian corridors and displacement camps and must operate with WHO-approved therapeutic feeding supplies and have access to emergency transport and field-compatible laboratory diagnostics wherever possible.

Their core functions should include:

  • Clinical triage of malnourished children.

  • Initiation of therapeutic refeeding under observation.

  • Electrolyte supplementation and thiamine prophylaxis.

  • On-the-ground training of local staff and volunteers.

These teams should be composed of:

  • Paediatricians and nutritionists with experience in managing severe acute malnutrition and refeeding complications.

  • Pharmacists and clinical support staff, capable of preparing and administering therapeutic feeds and supplements.

  • Community liaison officers, to follow up on at-risk children across displacement sites.

Empower and Train Mothers and Community Health Workers

In many cases, mothers are the first and only line of defence. Given the collapse of formal health services, community-based education becomes a frontline intervention. The majority of refeeding will occur in tents, shelters, or on the move—and it will be conducted by mothers, not medics. Rapid, mass-scale training programs should focus on:

  • Recognising signs of RFS: bradycardia, muscle weakness, seizures, confusion.

  • Understanding gradual refeeding: small, frequent meals, avoiding energy-dense snacks early on.

  • Knowing when to seek urgent help: refusal to feed, loss of consciousness, rapid swelling or breathing difficulty.

Establish Monitoring and Global Accountability Mechanisms

The global public health community must begin systematic monitoring of RFS-related morbidity and mortality in Gaza. Real-time data collection will enable rapid protocol adjustments, prevent repeated harm, and illuminate the scope of this silent killer. This includes:

  • Establish a centralised registry of suspected or confirmed RFS cases.

  • Encourage field reporting by NGOs, UN staff, and local health workers using simple digital or SMS-based tools.

  • Commission urgent operational research into RFS incidence, outcomes, and caregiver behaviour in Gaza's current conditions.

  • Track the timing and composition of food aid in relation to adverse events.

  • Publish case studies to raise global awareness and refine field guidance.

Refeeding Syndrome represents one of the most silent yet preventable causes of mortality in famine-stricken populations. In Gaza, where prolonged starvation now coexists with the collapse of clinical infrastructure, the conditions for a widespread metabolic disaster are already present. As humanitarian agencies scale up food distribution to avert famine-related deaths, they must also confront the reality that without integrated medical oversight, this well-intentioned aid risks accelerating the physiological decline of those it seeks to save.

Children, pregnant women, and chronically ill adults—already fragile from months of deprivation—require a highly specific form of care: gradual nutritional rehabilitation, supported by targeted electrolyte repletion and thiamine supplementation. This is not optional, nor is it complex. It is a matter of deploying established protocols, disseminating essential knowledge to caregivers, and ensuring that micronutrient and electrolyte supplies are prioritised as rigorously as calories.

In Gaza, the line between life and death is no longer defined solely by the presence or absence of food—but by the manner in which food is reintroduced. The window for prevention is narrow. The cost of inaction is irreversible. The time to respond with medically informed, coordinated intervention is now.

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