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
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
Arrythmias,Hypoventilati 0.6mmol/kg/day
(Normal 0.77–1.33mmol/l) on,Weakness,
Magnesium Sulphate (IV)
Vomiting,Loose motions.
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.
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
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. Appendix 6
Volume of F-75 to give for children of different weights
(see Appendix 7 for children with severe (+++ oedema)
of F-75 per feed (ml)a
Daily total
80% of daily totala
(130 ml/kg)
(minimum)
45
260
210
35
50
286
230
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
Weight
Volume
of child
Every 2 hoursb
Every 3 hoursc
Every 4 hours
(kg)
(12 feeds)
(8 feeds)
(6 feeds)
2.0
20
30
2.2
25
2.4
22. Appendix 7
Volume of F-75 for children with severe (+++) oedema
of F-75 per feed
(ml)a
Weight with
Volume
Daily total
80% of daily
+++ oedema
Every 2 hoursb
Every 3 hoursc
Every 4 hours
(100 ml/kg)
totala
(kg)
(12 feeds)
(8 feeds)
(6 feeds)
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
(minimum)
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 4hourly 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 .6H O 76gm, 3 mmol/20
2
2
ml
Zinc acetate: Zn acetate.2H 0 8.2gm, 300 µmol/20
2
ml
Copper sulfate: CuSO .5H O 1.4gm, 45 µmol/20 ml
4
2
Water: make up to 2500 ml
If available, also add selenium (0.028 g of sodium
selenate, NaSeO4.10H20) 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
