Refeeding in crisis settings: Implications on health care needs in Gaza

For months, humanitarian organizations and international agencies have sounded alarms over the imminent famine in Gaza.The Integrated Food Security Phase Classification (IPC) Report in March 2024 projected that, in the absence of cessation of hostilities and sustained access to essential aid and services including food, 1.1 million people-amounting to half the population in Gaza-will experience catastrophic food insecurity between mid-March and mid-July.Indeed, particularly in Northern Gaza, starvation has significantly increased, with rates of acute malnutrition rising from between 1% and 6.8% in January 2024 to between 12.5% and 16.5% the next month [1].The rise of widespread malnutrition raises significant concerns regarding the associated short, medium and long-term health consequences that will arise in the context of a collapsing health system in Gaza.As a direct consequence of severe acute malnutrition, children can experience wasting and death in the immediate term-from, for example, hypoglycemia, hypothermia, infection, dehydration, and anemia-and stunting over time [2].Malnourished children and adults are more vulnerable to severe illness of all causes [3]; in Gaza, this is exacerbated by the lack of access to water, sanitation and hygiene which has facilitated the spread of infectious disease such as Hepatitis A [1].Beyond these health impacts, evidence suggests that the consequences of malnutrition among children are life-long; lasting systemic inflammation may increase risks of cardiovascular and metabolic diseases in adulthood [4].What has been less well-described, however, is the monitoring that is required when malnourished individuals are re-fed, and the medical support that will be needed alongside attempts to restore food access in Gaza.Depending on the level of acute malnutrition a young child experiences, they require consistent community-based treatment at the least-including delivery of nutritional supplements, specialized nutritious foods specifically formulated to treat malnutrition, and possibly oral antibiotics-and hospital-based treatment for severe cases that require medical stabilization and more intensive care including IV medications [2].But even in older children and adults, healthcare needs to treat malnutrition can be significant.Namely, in the first one to two weeks that malnourished patients are fed, they are at heightened risk of electrolyte and fluid shifts that can result in severe medical complications including seizures, respiratory failure, cardiac arrest and death-otherwise known as refeeding syndrome [5].In countries such as the United States, individuals at high risk of re-feeding syndrome are typically observed carefully in medical facilities.These include patients who weigh less than 70% of ideal body weight or who have rapidly lost large amounts of weight due to conditions such as anorexia nervosa, alcohol use disorder, cancer, and other critical illnesses.Refeeding syndrome can be avoided, particularly for patients at highest risk, through daily observation of