Nutritional refeeding syndrome kwashiorkar and marasmus indore pedicon 2014

NUTRITIONAL REFEEDING SYNDROME,RECOVERY SYNDROME

1. NUTRITIONAL RECOVERY/
REFEEDING SYNDROME-
KWASHIORKAR AND
MARASMUS
Dr Rajesh Kulkarni
PUNE

2. MARASMUS AND KWASHIORKAR

3. CASE SCENARIO
Ram a 18 month old boy was brought to hospital
with c/o poor weight gain. He was 2.5 kg at birth
and 5 kg at 5 months of age but was given poor
quality complementary feeding.
His admission weight was 6.8 kg with a length of
64 cm.He was started on treatment protocol for
SAM patients.His glucose and temperature
stabilized over the next 24 hours.
On Day 3 ,he suddenly deteriorated with
respiratory distress and hypotension and
required PICU care.

4. WHAT IS REFEEDING SYNDROME?
Clinical complex, which includes electrolyte
changes associated with metabolic
abnormalities that can occur as a result of
nutritional support ( enteral or parenteral), in
severely malnourished patients.
Also called “the hidden syndrome”
History

5. PATHOPHYSIOLOGY

6. CLINICAL MANIFESTATIONS
 Nausea, vomiting, and lethargy
 Respiratory insufficiency, cardiac failure,
hypotension, arrhythmias, delirium, coma, and
death

7. DEFICIENCY CLINICAL FEATURES CORRECTION
Hypophosphataemia
(Normal 0.8 to 1.45
mmol/L)
heart failure, arrhythmia
acute tubular necrosis,
metabolic acidosis
Rhabdomyolysis
Seizures,Coma
0.1 – 0.36mmol/kg/day up
to 1.5mmol/kg/day
Phosphate IV [Max
70mmol/day]
Oral Joules solution
Hypomagnesemia
(Normal 0.77–1.33mmol/l)
 
Arrythmias,Hypoventilati
on,Weakness,
Vomiting,Loose motions.
0.6mmol/kg/day
Magnesium Sulphate (IV)
Thiamine Wernicke-Korsakoff
syndrome, psychosis,
congestive heart failure,
beriberi,
1ml (equivalent to 100mg
thiamine) should be
administered in 50-100ml
5% dextrose
over 30 minutes

8. REFEEDING SYNDROME
Refeeding a malnourished patient can result in
Heart failure due to:
Atrophic myocardium in malnutrition
Muscle depletion of Mg, K, P
Sodium and water overload

9. MANAGEMENT
Feeding and correction of biochemical
abnormalities can occur in tandem without
deleterious effects to the patient.(NICE)
Early identification of at risk individuals,
Monitoring during refeeding , and
An appropriate feeding regimen are important.

10. CLINICAL MONITORING
Monitor blood pressure and pulse rate
Monitor feeding rate
Meticulously document fluid intake and output
Account other sources of energy (dextrose,
medications)
Monitor change in body weight
Monitor for cardiac,respiratory and neurologic
signs and symptoms

11. LAB MONITORING
Monitor biochemistry and electrolyte
levels(initially 12 hourly).
Monitor blood glucose levels.
ECG monitoring in severe cases.

12. PARAMETER INITIATION PHASE MAINTANENCE
PHASE
WEIGHT Daily Weekly
SERUM
ELECTROLYTES
Daily,Then Thrice
Weekly
Weekly
SERUM CALCIUM,
MAGNESIUM,
PHOSPHOROUS
Daily,Then Thrice
Weekly
Weekly
LFT
Weekly
Weekly
PRE ALBUMIN Weekly Weekly
TRIGLYCERIDES Daily until lipid dose
stable
Weekly
GLUCOSE Initially 4 hourly,then as
guided clinically
As guided clinically

13. MANAGEMENT
Principle of Permissive Underfeeding
50 percent of estimated caloric requirement.
Dietician consult essential.
Avoid glucose/Carbohydrate overload

14. HOW MUCH TO FEED?
AGE FLUID
0-1 year 70 ml/kg
1-7 years 50 to 65 ml/kg

15. REFEEDING SYNDROME-TAKE
HOME MESSAGE
Children with SAM are at high risk of refeeding
syndrome (especially children who have SAM
with edema).
Feeds should be started cautiously and gradually
with MONITORING (both clinical and lab)
Hypophosphatemia ,Hypomagnesemia
,Hypokalemia and Thiamine deficiency can be
life threatening and should be treated
aggressively.

16. REFERENCES
Comprehensive Pediatric Hospital Medicine Lisa B. Zaoutis, Vincent W.
Chiang.637-639.
Refeeding Syndrome: A Literature Review
L. U. R. Khan, J. Ahmed, S. Khan, and J. MacFie
Gastroenterology Research and Practice
2011
Refeeding Syndrome in a Severely Malnourished Child Lab
Med. 2004;35(9)
Guidelines for management of SAM .Available from
http://nihfw.org/nchrc/Publication/Guidelines.Accessed on 01 January
2014

17.  Thank You!

18. HOW WE TREAT SAM PATIENTS-NRC

19. SAM PROTOCOL
PHASE
STABILISATION REHABILITATION
Step Days 1-2 Days 3-7 Weeks 2-6
1. Hypoglycaemia
2. Hypothermia
3. Dehydration
4. Electrolytes
5. Infection
no iron with iron
6. Micronutrients
7. Cautious feeding
8. Catch-up growth
9. Sensory stimulation
10. Prepare for follow-up

20. COMPOSITION OF F 75
CONTENT AMOUNT
MILK 30 ml
PUFFED RICE 3.5 gm
SUGAR 7 gm
OIL 2 ml
WATER 70 ml

21. Weight Volume of F-75 per feed (ml)
a
Daily total 80% of daily total
a
of child Every 2 hours
b
Every 3 hours
c
Every 4 hours (130 ml/kg) (minimum)
(kg) (12 feeds) (8 feeds) (6 feeds)
2.0 20 30 45 260 210
2.2 25 35 50 286 230
2.4 25 40 55 312 250
2.6 30 45 55 338 265
2.8 30 45 60 364 290
3.0 35 50 65 390 310
3.2 35 55 70 416 335
3.4 35 55 75 442 355
3.6 40 60 80 468 375
3.8 40 60 85 494 395
4.0 45 65 90 520 415
4.2 45 70 90 546 435
4.4 50 70 95 572 460
4.6 50 75 100 598 480
4.8 55 80 105 624 500
5.0 55 80 110 650 520
Appendix 6
Volume of F-75 to give for children of different weights
(see Appendix 7 for children with severe (+++ oedema)

22. Weight with Volume of F-75 per feed (ml)
a
Daily total 80% of daily
+++ oedema Every 2 hours
b
Every 3 hours
c
Every 4 hours (100 ml/kg) total
a
(kg) (12 feeds) (8 feeds) (6 feeds) (minimum)
3.0 25 40 50 300 240
3.2 25 40 55 320 255
3.4 30 45 60 340 270
3.6 30 45 60 360 290
3.8 30 50 65 380 305
4.0 35 50 65 400 320
4.2 35 55 70 420 335
4.4 35 55 75 440 350
4.6 40 60 75 460 370
4.8 40 60 80 480 385
5.0 40 65 85 500 400
Appendix 7
Volume of F-75 for children with severe (+++) oedema

23. FOR BOTH SAM WITH EDEMA &
WITHOUT EDEMA
Feed 2-hourly for at least the first day. Then,
when little or no vomiting, modest diarrhea (<5
watery stools per day), and finishing most feeds,
change to 3-hourly feeds.
After a day on 3-hourly feeds: If no vomiting, less
diarrhea, and finishing most feeds, change to 4-
hourly feeds.

24. SAM PROTOCOL
Give:
Extra potassium 3-4 mmol/kg/d
 
Extra magnesium 0.4-0.6 mmol/kg/d ( 0.3 ml/kg
of 50% magnesium sulfate IM ,Maximum 2
ml ).Day 2 onwards Injection can be mixed in oral
feedings.
When rehydrating, give low sodium rehydration
fluid (e.g. ReSoMal)
Prepare food without salt

25. MICRONUTRIENT SUPPLEMENTS
Vitamin supplement containing A,B complex
,C ,D and E at double the RDA.
Folic acid 5 mg on day 1,then 1mg/day.
Zinc 2mg/kg/day
Iron : NOT to be given in stabilization period. In
catch up period give 3 mg/kg/day.

26. COMPOSITION OF F 100
CONTENT AMOUNT
MILK 75 ml
PUFFED RICE 7 gm
SUGAR 2.5 gm
OIL 2 ml
WATER 25 ml

27. RESOMAL COMPOSITION
ReSoMal recipe
Ingredient
Water 2 litres
WHO-ORS One 1-litre packet*
 Sucrose 50 g
 Electrolyte/mineral solution 40 ml
(* 3.5 g sodium chloride, 2.9 g trisodium citrate
dihydrate, 1.5 g potassium chloride, 20 g glucose).

28. ELECTROLYTE/MINERAL
SOLUTION-COMPOSITION
 Potassium chloride: KCl 224 gm 24 mmol/20 ml
Tripotassium citrate 81gm, 2 mmol/20 ml
Magnesium chloride: MgCl
2
.6H
2
O 76gm, 3 mmol/20
ml
Zinc acetate: Zn acetate.2H
2
0 8.2gm, 300 µmol/20
ml
Copper sulfate: CuSO
4
.5H
2
O 1.4gm, 45 µmol/20 ml
Water: make up to 2500 ml
If available, also add selenium (0.028 g of sodium
selenate, NaSeO
4
.10H
2
0) and iodine (0.012 g of
potassium iodide, KI) per 2500 ml.

29. WHO ALTERNATIVE TO RESOMAL
2 LITRES WATER
1 PACK LOW OSMOLARITY ORS
45 ml Potassium Chloride solution(from stock
solution containing 100 gm KCL/Litre)
50 gm Sucrose