NUTRITIONAL RECOVERY/
REFEEDING SYNDROMEKWASHIORKAR AND
MARASMUS
Dr 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...
WHAT IS REFEEDING SYNDROME?


Clinical complex, which includes electrolyte
changes associated with metabolic
abnormalitie...
PATHOPHYSIOLOGY
CLINICAL MANIFESTATIONS


 Nausea, vomiting, and lethargy



Respiratory insufficiency, cardiac failure,
hypotension, ar...
DEFICIENCY

CLINICAL FEATURES

CORRECTION

Hypophosphataemia
(Normal 0.8 to 1.45
mmol/L)

heart failure, arrhythmia
acute ...
REFEEDING SYNDROME


Refeeding a malnourished patient can result in
Heart failure due to:
 Atrophic

myocardium in malnu...
MANAGEMENT


Feeding and correction of biochemical
abnormalities can occur in tandem without
deleterious effects to the p...
CLINICAL MONITORING

Monitor blood pressure and pulse rate
 Monitor feeding rate
 Meticulously document fluid intake and...
LAB MONITORING
Monitor biochemistry and electrolyte
levels(initially 12 hourly).
 Monitor blood glucose levels.
 ECG mon...
PARAMETER

INITIATION PHASE

MAINTANENCE
PHASE

WEIGHT

Daily

Weekly

SERUM
ELECTROLYTES

Daily,Then Thrice
Weekly

Weekl...
MANAGEMENT


Principle of Permissive Underfeeding



50 percent of estimated caloric requirement.



Dietician consult ...
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 ...
REFERENCES
Comprehensive Pediatric Hospital Medicine Lisa B. Zaoutis, Vincent W.
Chiang.637-639.
Refeeding Syndrome: A Lit...


Thank You!
HOW WE TREAT SAM PATIENTS-NRC
SAM PROTOCOL
PHASE
STABILISATION

Step

Days 1-2

1.

Dehydration

4.

Electrolytes

5.

Infection

6.

Micronutrients

7....
COMPOSITION OF F 75
CONTENT

AMOUNT

MILK

30 ml

PUFFED RICE

3.5 gm

SUGAR

7 gm

OIL

2 ml

WATER

70 ml
Appendix 6
Volume of F-75 to give for children of different weights
(see Appendix 7 for children with severe (+++ oedema)
...
Appendix 7
Volume of F-75 for children with severe (+++) oedema

of F-75 per feed

(ml)a

Weight with

Volume

Daily total...
FOR BOTH SAM WITH EDEMA &
WITHOUT EDEMA


Feed 2-hourly for at least the first day. Then,
when little or no vomiting, mod...
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 s...
MICRONUTRIENT SUPPLEMENTS


Vitamin supplement containing A,B complex
,C ,D and E at double the RDA.



Folic acid 5 mg ...
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
 Electrolyt...
ELECTROLYTE/MINERAL
SOLUTION-COMPOSITION
 Potassium chloride: KCl 224 gm 24 mmol/20 ml
 Tripotassium citrate 81gm, 2 mmol...
WHO ALTERNATIVE TO RESOMAL


2 LITRES WATER



1 PACK LOW OSMOLARITY ORS



45 ml Potassium Chloride solution(from stoc...
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Nutritional refeeding syndrome kwashiorkar and marasmus indore pedicon 2014

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NUTRITIONAL REFEEDING SYNDROME,RECOVERY SYNDROME

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Nutritional refeeding syndrome kwashiorkar and marasmus indore pedicon 2014

  1. 1. NUTRITIONAL RECOVERY/ REFEEDING SYNDROMEKWASHIORKAR AND MARASMUS Dr Rajesh Kulkarni PUNE
  2. 2. MARASMUS AND KWASHIORKAR
  3. 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. 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. 5. PATHOPHYSIOLOGY
  6. 6. CLINICAL MANIFESTATIONS   Nausea, vomiting, and lethargy  Respiratory insufficiency, cardiac failure, hypotension, arrhythmias, delirium, coma, and death
  7. 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. 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. 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. 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. 11. LAB MONITORING Monitor biochemistry and electrolyte levels(initially 12 hourly).  Monitor blood glucose levels.  ECG monitoring in severe cases. 
  12. 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 As guided clinically guided clinically
  13. 13. MANAGEMENT  Principle of Permissive Underfeeding  50 percent of estimated caloric requirement.  Dietician consult essential.  Avoid glucose/Carbohydrate overload
  14. 14. HOW MUCH TO FEED? AGE FLUID 0-1 year 70 ml/kg 1-7 years 50 to 65 ml/kg
  15. 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. 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. 17.  Thank You!
  18. 18. HOW WE TREAT SAM PATIENTS-NRC
  19. 19. SAM PROTOCOL PHASE STABILISATION Step Days 1-2 1. Dehydration 4. Electrolytes 5. Infection 6. Micronutrients 7. Cautious feeding 8. Catch-up growth 9. Sensory stimulation 10. Prepare for follow-up Weeks 2-6 Hypothermia 3. Days 3-7 Hypoglycaemia 2. REHABILITATION no iron with iron
  20. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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

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