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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 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, 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
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

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
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

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
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)

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
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)
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.
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: 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.
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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Nutritional refeeding syndrome kwashiorkar and marasmus indore pedicon 2014

  • 1. NUTRITIONAL RECOVERY/ REFEEDING SYNDROMEKWASHIORKAR AND MARASMUS Dr Rajesh Kulkarni PUNE
  • 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
  • 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 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. 
  • 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. 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
  • 18. HOW WE TREAT SAM PATIENTS-NRC
  • 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. 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