How to Feed an Emaciated Horse to Avoid Refeeding Syndrome

Emaciated Horses
Refeeding Syndrome
Diagnosis
Prognosis
Protocol
Nutrition
Management
Signs

Emaciated horses have a very low body condition score with extensive loss of muscle and fat.

Horses with a history of neglect and starvation are at risk of serious health issues, including negative effects on their heart and digestive tract.

These severely underweight horses need to be carefully managed with veterinary care and precise nutrition strategies during their recovery.

Reintroducing feed must be done slowly to allow your horse’s body to adjust. Otherwise, rapid metabolic changes can cause life-threatening complications.

If you have rescued a skinny horse, start by feeding small meals of high protein forages, such as alfalfa hay. Avoid feeding grains or other supplements at the beginning of refeeding programs to prevent Refeeding Syndrome.

Caring for Emaciated Horses

When a horse’s energy requirements are not met, she initially uses body fat and carbohydrate (sugar) stores to support necessary bodily processes. After fat and carbohydrate stores are depleted, she will begin breaking down body protein to meet her energy needs. ^[1]

When we think of body protein stores, we think of muscles. Indeed, horses who don’t get enough energy will break down muscle tissue and lose muscle mass.

However, during times of extreme energy restriction such as starvation, other body stores of protein including heart and gastrointestinal tissue may also be broken down.

The deterioration of cardiac and digestive tissues is accompanied by changes in metabolism that can lead to complications and health issues, which should be addressed by a professional.

For this reason, every refeeding program should begin with veterinary care and close monitoring.

Refeeding Syndrome

Refeeding Syndrome occurs when emaciated horses are reintroduced to proper nutrition too quickly. In healthy horses, consuming a meal increases blood glucose concentrations, stimulating insulin release.

The same is true of emaciated horses, but alterations in insulin-stimulated mineral and electrolyte metabolism in these horses can cause life-threatening complications such as edema, diarrhea, neurological issues, and heart failure. ^[2]

Refeeding syndrome is not triggered by a single meal but develops over a few days to a week. Refeeding emaciated horses for weight gain must be done carefully, under close veterinary supervision, to limit factors that can precipitate health complications.

Veterinary Consultation

Regular, frequent vet assessment is critical, especially at the beginning of refeeding programs for skinny horses.

Below are several common health issues that your vet will likely check for and monitor:

Dental Issues

Poor dentition can be both a cause of starvation and an effect of neglect. Neglected horses often receive inadequate dental care, which can lead to dental issues that limit their intake of forages.

Poor dental health can also contribute to weight loss and impact refeeding strategies. If your vet determines that your horse has dental issues, you can soak feeds such as forage pellets to make meals easy to consume.

Parasitic Infections

Return to a normal deworming schedule can alleviate parasitic infections and promote weight gain. ^[3]

However, if your horse is extremely thin at the beginning of refeeding, it may be beneficial to wait to implement a worming program until their health is stable. ^[2]^{[ 4]}

Consult closely with your veterinarian to determine the safest strategy and timeline to deworm your horse.

Infection and Chronic Inflammation

Chronic infections can contribute to weight loss, but starvation can also increase susceptibility to infection and lead to chronic inflammation. ^[5]

Establishing a regular vaccination program should be done carefully and under the advisement of a veterinarian. ^[4]

Anemia

Anemia is common in emaciated horses and may be caused by underlying medical issues such as parasitic infections, subclinical infections, or chronic inflammation associated with starvation. ^[6]

Consult with your vet to determine if these underlying issues may be causing the observed anemia and to determine a safe program to correct them.

Biochemical Abnormalities

Your vet will monitor circulating concentrations of minerals and electrolytes like phosphorus, magnesium, and potassium.

These levels may be normal before refeeding, but low circulating levels of phosphate, also known as hypophosphatemia, is the hallmark of refeeding syndrome. Your veterinarian will likely monitor circulating potassium, magnesium, and thiamine, as low levels can signal the onset of refeeding syndrome. ^[2]

Your vet may take samples from your horse daily during the first week of refeeding and several times weekly through the first three weeks to ensure that your horse does not develop refeeding syndrome. ^[2]

Metabolic Issues, Laminitis and Founder

Metabolic disease can both cause and be a consequence of poor body condition. Refeeding can also exacerbate underlying metabolic diseases.

Monitor your horse closely for signs of laminitis or founder during refeeding. Contact your vet immediately if your horse shows any of these signs of laminitis during refeeding:

Increased time spent lying down
Reluctance to move
Walking very gingerly
Rocking back on the hind legs

Length of Recovery & Prognosis

The amount of time your skinny horse will take to recover will depend on several factors including how long their nutrient intake was limited, how much weight they need to regain, and whether they have additional health issues.

You may see some improvement in weight and condition as early as the first month of rehabilitation. ^[7] Full recovery of body condition for emaciated horses can take anywhere from three to ten months, depending on the horse’s condition at the start of refeeding. ^[7]

Your horse’s recovery will depend on proper veterinary care, a good nutrition program, and a lot of patience, but it will be well worth it in the end.

It is important to recognize the reality of rehabilitating emaciated horses. An estimated 20 percent of emaciated horses may die while being refed, and others may respond poorly to dietary changes despite the best refeeding plan. ^[2]^[4]

Careful, responsive feeding management is critical to improving the prognosis for emaciated horses.

Refeeding Protocol

There is no one size fits all refeeding program, but the recommended program below is evidence-based and provides a good starting point. ^[1]^[2]^[7]

To formulate the best feeding plan for your skinny horse, submit a hay sample for analysis to determine the energy and protein content of your hay. This will help you decide how much hay to feed per day.

Monitor your horse closely, especially at the beginning of the refeeding diet to watch for signs of refeeding syndrome, laminitis, or other complications.

Days 1 – 3

Hay: 0.5 kg / 1 lb of high-quality alfalfa every 4 hours
Grain: None
Other Supplements: None

If your horse hasn’t had hay for the 24 hours preceding refeeding, you can try offering hay by hand at hourly intervals for the first day.

Aim to feed 50% of the dietary energy requirement (likely just over one flake of alfalfa hay) in six feedings over 24 hours.

The ideal alfalfa hay will be leafy with fine stems, no dust or mold, and a 16-20% crude protein content.

Avoid salt blocks during the first couple of weeks of refeeding. Alfalfa should provide a safe amount of minerals and electrolytes for refeeding.

Avoid feeding grain, treats, and supplements until your horse is well along in their recovery.

Days 4 – 5

Hay: 0.9 – 1.4 kg (2 – 3 lb) of high-quality alfalfa every 4 hours
Grain: None
Other Supplements: None

Aim to feed 75% of the dietary energy requirement (approximately 2 flakes of alfalfa hay) in six feedings over 24 hours.

Days 6 – 10

Hay: 1.8 – 2.3 kg (4 – 5 lb) of high-quality alfalfa every 4 hours
Grain: None
Other Supplements: None

Aim to feed 100% of the dietary energy requirement (approximately 2.5 flakes of alfalfa hay) in three feedings over 24 hours.

Days 10 – 120

Hay: Slowly increasing amounts of high-quality alfalfa every 8-12 hours. You can also begin to add grass hay slowly.

Grain: When your horse has a body condition score of 2 or higher and is recovering well, slowly introduce small (0.25 kg/ 0.5 lb) grain meals.

Other Supplements: When your horse is well along in their recovery, begin slowly adding a comprehensive vitamin/mineral supplement such as Omneity over the course of a couple of weeks.

After six weeks, if your horse is recovering well, you can also consider adding small amounts of salt, increasing to 15 – 30 grams of loose salt over the course of a couple of weeks.

Consult your veterinarian and a nutritionist to choose a safe grain for refeeding.

When choosing a grain for refeeding, aim for one that is low in starch and sugar. Alfalfa pellets or cubes, soaked or rinsed beet pulp, and flax seed are good options.

When introducing grain, aim to feed 4 – 6 small meals per day. Monitor their intake and watch closely for signs of refeeding syndrome or digestive upset.

After two weeks of small grain meals, you can begin feeding larger meals 2 – 3 times per day.

6 Key Considerations for Refeeding

There are many considerations for when and how to reintroduce different dietary components to an emaciated horse. Careful management can make the difference between a healthy recovery and a spiral into refeeding syndrome.

1) Water

Refeeding should start with water. Allow your horse access to fresh, clean water at all times of your day.

If the horse is in a group setting, ensure there are multiple water sources to allow horses lower in the social hierarchy adequate access to water.

2) Hay

Feeding high quality alfalfa hay can limit the likelihood of refeeding syndrome. Alfalfa is relatively low in sugar and starch, but high in protein and calories.

Alfalfa also provides a healthy dose of important nutrients, such as phosphorus, magnesium, and electrolytes. ^[1]

Be sure to reintroduce hay slowly, starting with high-quality alfalfa. After a couple of weeks, you can slowly add good-quality grass hay to the diet. ^[1]

If you are refeeding a horse over the winter, providing hay will also increase their hindgut fermentation, which may help to keep them warm.

Avoid low-quality or fibrous hays as they can irritate the digestive tract and cause diarrhea. ^[1]^[7]

Lower-quality hays are also often lower in protein, energy and mineral content compared to higher-quality hays and alfalfa. ^[1]

3) Pasture

Once your horse is stable and doing well on a hay-based diet, consult your veterinarian about reintroducing them to pasture.

If your pasture is lush, limit pasture access to three to four times per day for one or two hours to avoid excess non-structural carbohydrate (NSC) intake. This can help reduce the risk of pasture-associated lamintis. ^[7]

4) Grain

Once your horse is stable and doing well on a forage-based refeeding program, you may want to add a commercial grain product to their diet. Note that horses do not require grain in their diet and can thrive on a forage-based feeding plan.

If you do choose to feed a grain concentrate, select a grain that is low in sugars and starches, molasses free, and ideally alfalfa-based. ^[1]

You can reintroduce grain after a couple of weeks if your horse is doing well and above a body condition score of 2. ^[2] Reintroduce grain slowly, with small meals offered several times daily, to avoid triggering refeeding syndrome.

The grain you choose should provide adequate energy and protein to support weight gain but limit sugar and starch intake. ^[1]^[2]^[7]

Look at the following nutrient components on the feed tag when choosing a grain to refeed your horse:

Sugar and Starch

Non-structural carbohydrates (NSC, or sugar and starch) should be low (ideally around 10-12%) in your chosen grain.

High NSC feeds may cause a rapid rise in blood glucose and insulin, triggering refeeding syndrome. ^[1]^[2]^[7]

Fat

Fat sources should not replace calories from alfalfa early in refeeding programs. Alfalfa is high in protein, phosphorus, and magnesium, which can be beneficial for emaciated horses. ^[1]

However, omega-3-rich fat sources are a good, energy-dense option when your horse is well on the road to recovery. ^[7]

Oils that are high in the omega-3 fatty acid DHA may also provide anti-inflammatory support, which can be helpful if your horse has infections or chronic inflammation related to poor nutrition.

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Protein

Aim to feed a grain that provides around 12% crude protein. ^[7] Emaciated horses often lose substantial muscle mass.

Thus, refeeding requires extra protein to support rebuilding muscle mass and topline. Aim to provide protein at 20% above their maintenance requirement. ^[7]

Make sure to provide a protein source with a good balance of lysine, threonine, and methionine, or provide additional amino acid supplementation to support muscle growth.

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Fiber

Aim for a feed with a good soluble fiber source to promote hindgut health.

Be sure to reintroduce grain gradually, starting with small, frequent meals and building to larger, less frequent meals. Although it is tempting to feed a lot of grain to encourage weight gain, more problems will be caused by exceeding your horse’s requirements.

5) Vitamin and Mineral Supplement

A comprehensive vitamin and mineral supplement will support healthy weight gain and metabolism while addressing nutrient deficiencies.

Look for a supplement that provides adequate thiamine, phosphorus, and magnesium, as these nutrients are often depleted in emaciated horses. ^[2] Be sure to introduce supplements slowly to avoid digestive upset or triggering refeeding syndrome.

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6) Electrolytes

Emaciated horses often have depleted stores of the electrolyte minerals potassium and chloride. ^[2]^[5] Adding an electrolyte supplement may help replenish these minerals to promote healthier metabolism and encourage water consumption. ^[5]^[6]^[7]

Always check with your veterinarian before adding electrolytes to a refeeding program. Your veterinarian may want to run laboratory tests to ensure your horse is not exhibiting biochemical signs of refeeding syndrome.

If your horse is doing well after a couple of weeks on their refeeding program, you can introduce electrolyte supplements or salt slowly. ^[1]

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Management Considerations

When refeeding an emaciated horse, remember the eight following care and management practices:

1) Refeed Slowly to Targeted Percentages of Energy Requirements

Begin refeeding by providing 50% of your horse’s maintenance requirement and gradually increasing to 100% of their requirement over a couple of weeks. ^[2]

Consult with a nutritionist to ensure you feed the correct amount of energy during refeeding.

2) Conduct a Forage Analysis

The energy density of hays is variable, so conducting a hay and/or pasture analysis will ensure that your horse gets what they need during refeeding. ^[2]

3) Feed Small Meals

Gastric volume, emptying, and nutrient absorption are often impaired in emaciated horses. ^[3] Small meals will prevent overwhelming your underweight horse’s recuperating digestive system.

4) Consider a Gastroprotectant

Emaciated horses can suffer from digestive issues that limit their ability to absorb nutrients and maintain weight. ^[1]

Consult with your vet to determine whether your horse has ulcers, and consider giving a supplement to support their gastric and/or hindgut health.

5) Avoid Stress

Stress can lead to increased energy expenditure and exacerbate health issues. ^[1] Make sure your horse is turned out with appropriate companions to minimize stress.

This is especially important because emaciated horses often exhibit abnormal feeding habits, such as food aggression and pica (eating soil and foreign objects), which may not resolve after refeeding. ^[1]

6) Blanket in Cold Weather

If your horse is cold, she will have to expend additional energy to keep herself warm. This can slow down weight gain and recovery.

If you are starting a refeeding program in the winter, keep your horse warm by providing adequate shelter and consider blanketing.^[1]

7) Take Notes

You should record your horse’s body weight, body condition score, water intake, and feed intake regularly and monitor them for changes.

You can estimate your horse’s weight with a weight tape if you do not have access to a livestock scale.

8) Be Flexible

Every refeeding situation is unique, so be ready to make adjustments based on your horse’s progress.

Signs of Refeeding Syndrome

Slowly introduce dietary changes when refeeding emaciated horses. Be sure to watch for the following concerning signs during refeeding, which indicate you should call your veterinarian:

Concerning Signs

Diarrhea
Edema (swelling)
Cardiac abnormalities, such as arrhythmias or increased or decreased heart rate
Neurological symptoms, such as weakness, signs that your horse is experiencing tingling or numbness in the lower limbs, or tremors
Signs of laminitis or founder, such as increased time spent lying down, reluctance to move, walking very gingerly or rocking back on the hind legs ^[2]

Good Signs

The following signs indicate that your refeeding program is working well and your horse is gradually recovering:

You may notice improvements in eye, ear, and head movement after a couple of weeks ^[1]
You may notice an increase in weight gain after about a month ^[7]
Depending on their condition at the beginning of the refeeding program, you can expect your horse to be back to a normal weight within 3-10 months ^[7]

Conclusion

Refeeding syndrome can be life-threatening, but it can be avoided with careful veterinary and nutritional management and close monitoring.

Consult a veterinarian before you begin refeeding an emaciated horse to address underlying issues such as poor dentition, parasitic or other infections, anemia, biochemical abnormalities, and metabolic disease.

Your vet may also be able to give you more information on your horse’s prognosis and estimate how long it will take them to recover.

Your refeeding program should focus on providing small amounts of high-quality forage to start with. Over time, you can gradually reintroduce additional components – such as grain, vitamin and mineral supplements, and electrolytes – to support healthy weight gain.

Be vigilant for signs of refeeding syndrome and be flexible with your feeding program as every horse responds differently.

You can submit your horse’s information online for a free consultation with our equine nutritionists to ensure your horse is on the safest path to a speedy recovery.