Eating disorders: refeeding and multidisciplinary-care OSCE — risk stratification, refeeding-syndrome prevention and family engagement

Station objectives

1. Classify refeeding risk and complete the safe-preparation checklist before the first feed. [1]
2. Design a refeeding regimen with thiamine and a phosphate–magnesium–potassium monitoring plan, and justify the calorie-start choice from the evidence. [3]
3. Recognise and immediately manage evolving refeeding syndrome. [1]
4. Engage anxious parents in family-based treatment with a non-blaming, structured frame. [5]

Candidate brief

You are the paediatric doctor on the adolescent ward. You have 10 minutes for Station A (preparing to refeed a newly admitted patient and engaging her parents) and 8 minutes for Station B (day-two deterioration with a falling phosphate). Examiners score safety, evidence, communication and partnership language. [1] [6]

Station A — Preparing to refeed and engaging the family

Setup: A 14-year-old with restricting-type anorexia nervosa, 71% median BMI, minimal intake for a week, 6 kg lost in two months. Baseline phosphate 0.80 mmol/L, potassium 3.3 mmol/L, magnesium 0.70 mmol/L; heart rate 44 supine to 78 standing; QTc 470 ms. Her parents are frightened and worried they caused the illness. [1] [6]

Expected actions:

• Classify her as high refeeding risk and state the stacked risk factors. [1]
• Complete the safe-preparation checklist: baseline biochemistry done; give thiamine before or with the first feed; correct the baseline phosphate, potassium and magnesium deficits; document the prolonged QTc and plan to repeat the ECG; set a calorie start matched to her risk. [1] [2]
• Set up serial monitoring: phosphate, potassium and magnesium daily (consider twice-daily in the first 48–72 hours), daily weight and orthostatic vitals. [3]
• Brief the nursing team on supervised meals, post-meal observation, exercise restriction and bathroom monitoring. [6]
• Explain to the parents, without blame, that they did not cause the illness and that family-based treatment makes them central to recovery: in phase 1 they take full, supported charge of her nutrition. Reassure them that phase-1 resistance is expected, not failure. [5]

Station B — Day-two falling phosphate

Setup: On day two of refeeding her phosphate has fallen from 0.80 to 0.45 mmol/L; potassium 3.1 mmol/L. She reports mild palpitations. [1]

Expected actions:

• Recognise evolving refeeding syndrome: phosphate is the sentinel marker and it is falling; the palpitations raise arrhythmia concern. [1] [2]
• Slow or briefly pause the feed; give intravenous phosphate per protocol; correct potassium and magnesium (magnesium must be adequate for potassium to correct); confirm thiamine has been given. [1]
• Monitor cardiac rhythm, repeat the ECG and QTc; escalate to high-dependency if there is haemodynamic instability, respiratory compromise or dangerous arrhythmia. [1]
• Resume feeding at a rate the biochemistry tolerates once corrected; do not abandon nutritional rehabilitation. [3]

Marking anchors

Clear pass: correctly classifies high refeeding risk; completes thiamine, baseline-electrolyte correction and matched calorie start; sets up daily biochemistry; recognises the falling phosphate as refeeding syndrome and acts immediately with IV phosphate and feed modulation; engages parents without blame and frames FBT phase 1; names the evidence (STRONG) and a guideline. [1] [3] [5] Borderline: good rapport but vague on monitoring frequency, reactive rather than proactive phosphate, or uncertain on the calorie evidence. Fail: starts feeding without thiamine or baseline-electrolyte correction; misses the falling phosphate; over-resuscitates with fluids; blames the parents; discharges intent without a monitoring or FBT plan. [1] [6]

Debrief pearls

• The first sign of refeeding syndrome is on the blood form, not the monitor — act on the phosphate trend before bedside decompensation. [2]
• Higher-calorie refeeding is evidence-supported only when paired with intensive monitoring and proactive replacement — the safety precondition, not the calorie number, is the point. [3] [4]
• Parents are the treatment, not the cause: FBT makes the family central to recovery from day one. [5]