Refeeding syndrome

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Refeeding syndrome

• Nutrition Department

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Definition

• Refeeding syndrome is a potentially fatal
  condition,caused by rapid initiation of refeeding
  after a period of undernutrition
• characterised by hypophosphataemia, associated
  with fluid and electrolyte shifts and metabolic
  and clinical complications

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Refeeding syndrome

• Refeeding syndrome is a well described but often
  forgotten condition.
• No RCT of treatment have been published
• Best available evidence for managing the
  condition?guideline NICE 2006/ England
• Cohort studies, case series, and consensus expert
  opinion

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How common?

• The true incidence of RS is unknown
• a study of 10 197 hospitalised patients 0.43
  severe hypophosphataemia (malnutrition one of
  the strongest risk factors)
• Not contain phosphorus TPN 100
  hypophosphataemia (vs 18 if P contain)
• Cohort study in ICU 34 HP soon after feeding
  was started (SD 1.9 1.1 days)

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pathogenesis prolonged fasting

• preventing protein and muscle breakdown (use of
  ketone bodies and fatty acids as the main energy
  source, ? gluconeogenesis),
• severely depleted intracellular minerals but
  normal serum concentrations
• Reduction in renal excretion.

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pathogenesis Refeeding

• ? glycemia ? insulin and ?glucagon secretion
• Insulin stimulates glycogen, fat, and protein
  synthesis.(requires P,Mg, cofactors such as
  thiamine)
• absorption of potassium into the cells through
  the Na,K ATPase symporter (
• transports glucose into the cells)
• Water follows by osmosis

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Results

• ? P ?ATP, change in O2 delivery to tissues, acid
  base buffer, cell membranes integrity.
• ? K derangements in the electrochemical membrane
  potential?arrhythmias and cardiac arrest.
• ? Mg cardiac dysfunction, neuromuscular
  complications
• Vitamin deficiency B1 ? Wernickes
  encephalopathy (ocular abnormalities, ataxia,
  confusional state, hypothermia, coma) or
  Korsakoffs syndrome (retrograde and anterograde
  amnesia, confabulation)
• Sodium, nitrogen, and fluid rapid ? in renal
  excretion of sodium and water? cardiac failure,
  pulmonary oedema, and cardiac arrhythmia if try
  to maintain a normal urine output

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Prevention high risk patients

• Criteria from the guidelines of the National
  Institute for Health and Clinical Excellence for
  identifying patients at high risk of refeeding
  problems (level D recommendations)
• Either the patient has one or more of the
  following
• Body mass index (kg/m2) lt16
• Unintentional weight loss gt15 in the past three
  to six months
• Little or no nutritional intake for gt10 days
• Low levels of potassium, phosphate, or magnesium
  before feeding
• Or the patient has two or more of the
  following
• Body mass index lt18.5
• Unintentional weight loss gt10 in the past three
  to six months
• Little or no nutritional intake for gt5 days
• History of alcohol misuse or drugs, including
  insulin, chemotherapy, antacids, or diuretics

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NICE guidelines recommendation

• Refeeding is started at no more than 50 of
  energy requirements
• Increased to meet or exceed full needs over 4-7
  days
• High risk patients tailored to each patient
• Very malnourished patient cardiac monitoring
• Correcting electrolyte and fluid imbalances
• before feeding is not necessary and that this
• should be done along with feeding.

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NICE guidelines recommendation

• Vitamin supplementation should also be started
  with refeeding and continued for at least 10 days
• Circulatory volume should also be restored.
• Oral, enteral, or intravenous supplements of K,
  P,Ca, Mg should be given unless blood levels are
  high before refeeding

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P, Mg supplementation
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(No Transcript)
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Treatment of the Malnourished child

• Essential features of the initial feeding are
• Frequent small feeds of low osmolality and low in
  lactose
• Oral or nasogastric feeds (never IV feeds)
• 100 kcal/kg/day
• Protein 1-1.5 gm/kg/day
• Liquid 130 ml/kg/day (100 if child has severe
  edema)
• Continue with breastfeeding but give scheduled
  amounts of formula first

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Treatment of the Malnourished child

• Clinical status must be monitored carefully
• Child should be fed every 2 hours for 1st day or
  2, then every 3 hours until day 6
• If childs intake does not reach 80 kcal/kg/day
  despite frequent feeds, coaxing and re-offering,
  the remaining feed should be given by nasogastric
  tube

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Treatment of the Malnourished child

• Return of the appetite is the sign for entering
  the rehabilitation phase
• Usually about 1 week after admission
• During this phase very high intakes are
  encouraged to support a weight gain of gt 10
  g/kg/day
• Must be alert to avoid heart failure (rapid pulse
  and fast breathing) if intake is high suddently)
• Modified porridges or complementary foods can be
  used if comparable in energy an pro

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Treatment of the Malnourished child

• Increase each feed by 10 ml until some remains
  uneaten
• Likely to occur when intakes reach about 200
  ml/kg/day
• After a gradual transition, give
• Frequent feed, unlimited amounts
• 150-220 kcal/kg/day
• 4-6 g/kg/day of protein

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REFERENCE SOURCES AND SELECTION CRITERIA

• search the databases Medline,Embase, PubMed,
  Cochrane, CINAHL, and AMED (Allied and
  ComplementaryMedicine Database), as well as cross
  checking with reference lists, textbooks, and
  personal reference lists
• assessed the quality of evidence in original
  articles according to guidelines published on the
  Evidence-Based On-Call website
• Downloaded from bmj.com on 22 October 2008
• Clinical review Refeeding syndrome what it is,
  and how to prevent and treat it
• Hisham M Mehanna,Jamil Moledina,Jane Travis

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REFERENCE

• 1. Refeeding Syndrome in a Severely Malnourished
  Child
• www.medscape.com/viewarticle/489090_4
• 2. Refeeding syndrome Is underdiagnosed and
  undertreated, but treatable
• Stephen D Hearing, consultant gastroenterologist
  
• Department of Gastroenterology, Staffordshire
  General Hospital, Weston Road, Stafford
• 3. Refeeding syndrome life-threatening,
  underdiagnosed, but treatable
• qjmed.oxfordjournals.org/cgi/content/full/98/4/31
  8-a

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THANKS FOR YOUR ATTENTION!