NUTRITIONAL RECOVERY/REFEEDING SYNDROME-KWASHIORKAR AND MARASMUSDr Rajesh Kulkarni

PUNE

MARASMUS AND KWASHIORKAR

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.

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

PATHOPHYSIOLOGY

CLINICAL MANIFESTATIONS

 Nausea, vomiting, and lethargy

Respiratory insufficiency, cardiac failure, hypotension, arrhythmias, delirium, coma, and death

DEFICIENCY CLINICAL FEATURES CORRECTION

Hypophosphataemia(Normal 0.8 to 1.45 mmol/L)

heart failure, arrhythmiaacute tubular necrosis, metabolic acidosisRhabdomyolysisSeizures,Coma

0.1 – 0.36mmol/kg/day up to 1.5mmol/kg/day Phosphate IV [Max70mmol/day]

Oral Joules solution

Hypomagnesemia(Normal 0.77–1.33 mmol/l)

Arrythmias,Hypoventilation,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% dextroseover 30 minutes

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

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.

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

LAB MONITORING

Monitor biochemistry and electrolyte levels(initially 12 hourly).

Monitor blood glucose levels. ECG monitoring in severe cases.

PARAMETER INITIATION PHASE MAINTANENCE PHASE

WEIGHT Daily Weekly

SERUM ELECTROLYTES

Daily,Then Thrice Weekly

Weekly

SERUM CALCIUM,MAGNESIUM,PHOSPHOROUS

Daily,Then Thrice Weekly

Weekly

LFTWeekly

Weekly

PRE ALBUMIN Weekly Weekly

TRIGLYCERIDES Daily until lipid dose stable

Weekly

GLUCOSE Initially 4 hourly,then as guided clinically

As guided clinically

MANAGEMENT

Principle of Permissive Underfeeding

50 percent of estimated caloric requirement.

Dietician consult essential.

Avoid glucose/Carbohydrate overload

HOW MUCH TO FEED?

AGE FLUID

0-1 year 70 ml/kg

1-7 years 50 to 65 ml/kg

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.

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

Thank You!

HOW WE TREAT SAM PATIENTS-NRC

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 iron6. Micronutrients

7. Cautious feeding

8. Catch-up growth

9. Sensory stimulation

10. Prepare for follow-up

COMPOSITION OF F 75

CONTENT AMOUNT

MILK 30 ml

PUFFED RICE 3.5 gm

SUGAR 7 gm

OIL 2 ml

WATER 70 ml

Weight Volume of F-75 per feed (ml)a Daily total 80% of daily totala

of child Every 2 hoursb Every 3 hoursc 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 6Volume of F-75 to give for children of different weights(see Appendix 7 for children with severe (+++ oedema)

Weight with Volume of F-75 per feed (ml)a 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) (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 7Volume of F-75 for children with severe (+++) oedema

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.

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

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.

COMPOSITION OF F 100

CONTENT AMOUNT

MILK 75 ml

PUFFED RICE 7 gm

SUGAR 2.5 gm

OIL 2 ml

WATER 25 ml

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).

ELECTROLYTE/MINERAL SOLUTION-COMPOSITION

 Potassium chloride: KCl 224 gm 24 mmol/20 ml Tripotassium citrate 81gm, 2 mmol/20 ml Magnesium chloride: MgCl2.6H2O 76gm, 3

mmol/20 ml Zinc acetate: Zn acetate.2H20 8.2gm, 300

µmol/20 ml Copper sulfate: CuSO4.5H2O 1.4gm, 45 µmol/20 ml 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.

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