Supporting Weight Regain (The Role of Parents During the Refeeding Phase)

"Refeeding" refers to the phase in which a child or adolescent, after a prolonged period of starvation due to anorexia nervosa, begins to eat regularly and sufficiently again so that their weight increases.

During periods of starvation, the body slows down its metabolism. Heart rate, circulation, and digestion operate at a minimal level. When food intake increases again, the body must adjust gradually. For this reason, calorie intake is increased in small increments rather than all at once.

In inpatient treatment, the goal is often a weight gain of about 0.3 to 1 kilogram per week. The treatment team sets these targets and adjusts them based on the child’s condition. For parents, this is a long journey marked by both progress and setbacks.

Eating too quickly can be dangerous. Experts refer to this as refeeding syndrome. When a starved body suddenly receives a large amount of carbohydrates, minerals such as phosphate, potassium, and magnesium shift from the blood into the cells. Blood levels drop. This can disrupt heart rhythm, muscle function, and the nervous system, and in the worst case, be life-threatening.

In cases of anorexia nervosa, up to 28 percent of patients receiving inpatient treatment develop this type of metabolic imbalance. For this reason, nutritional therapy in high-risk cases begins cautiously, often at around 10 kilocalories per kilogram of body weight per day, with a gradual increase. Electrolyte levels are closely monitored during the first few days—usually every one to two days—and thiamine is supplemented.

Important for parents: Never increase meal portions on your own at home in an attempt to reach the goal faster. The attending physician determines how much and how quickly to increase food intake based on blood test results and cardiovascular monitoring.

In family-based therapy (FBT), parents consciously take responsibility for mealtimes during the first phase. Not because the child is incapable of making decisions, but because the illness makes it particularly difficult for the child to make these decisions.

Structure helps: set mealtimes, a calm environment, and someone sitting with the child and staying nearby for a while after the meal. The portion size is determined by the treatment team’s nutrition plan and is not renegotiated at the table. Avoid conversations about calories, weight, or fat on the plate. Talk about the school day, the dog, or yesterday’s TV show.

This support is demanding and often requires two adults taking turns. It involves paying close attention without pressuring the child (more on this under “monitoring controlled eating”).

Weight gain triggers intense anxiety in many affected individuals. At the dinner table, this can lead to crying, anger, withdrawal, or bargaining. Often, in such moments, it is the illness speaking, not the child’s true desire.

A calm, warm, and firm approach is helpful. Show understanding for their anxiety while still insisting on the meal. Short, friendly sentences work better than long explanations. Discussions about portion sizes rarely get you anywhere and drain everyone’s energy.

Expect that there will be days with setbacks. A difficult evening does not mean a relapse into old patterns (see “Relapse from a Parent’s Perspective” for more background). Discuss difficult situations with the treatment team; they can provide you with specific phrases and strategies for your next attempt.

The refeeding phase should be managed at a specialized facility. In cases of severe underweight, rapid weight loss, or physical warning signs such as dizziness, heart palpitations, or fluid retention, medical supervision is urgently needed. Points of contact include child and adolescent psychiatry departments, specialized outpatient clinics for eating disorders, and the treating pediatricians.

Rückenwind Rückenwind is here to guide you as parents through this time, provide structure, and offer support. However, cannot make a diagnosis or oversee medical refeeding. This is the exclusive responsibility of a child and adolescent psychiatry department or a medical or psychotherapeutic specialist.