4. Clinical Features of Malnutrition

4.2. The Refeeding Syndrome

Complications of refeeding syndrome include:

  • Hypomagnesemia
  • Hypoglycemia
  • Hypokalemia
  • Hypophosphatemia
  • Thiamine deficiency

During starvation, there is a redistribution of proteins, fluids, and electrolytes, as the body tries to adapt to the state of malnutrition. Acidosis, associated with the catabolic state, leads to a potassium shift from the intracellular compartment into the blood. Elevated aldosterone levels result in total body potassium depletion (similar to that found in diabetic ketoacidosis). Reintroduction of fluids and carbohydrates, via oral, enteral, or parenteral routes, produces a sudden shift back to glucose as the predominant fuel source, leading to increased demand for phosphorylated intermediates of glucose metabolism, increased insulin production, and the shift of potassium back into the cells associated with the resolution of the acidosis. This results in hypokalemia and hypomagnesemia. Acute thiamine deficiency syndrome shares many common elements with the refeeding syndrome but is a separate entity. It is also very frequent in children with Severe Acute Malnutrition. The refeeding process with carbohydrate drives a rapid use of Thiamine that produces a “functional Thiamine deficiency” aggravated by low thiamine body stores.

New studies of cardiac function in children with severe acute malnutrition do not support the long held belief that these children have poor function and will not tolerate a high volume of fluids. Insulin may play a key role in the development of pulmonary edema and congestive heart failure in these children by exerting an anti-diuretic effect leading to sodium and water retention that result in the expansion of the extracellular water ­compartment.

Therefore, it is necessary to ­reassess the patient repeatedly and develop an appropriate management plan to avoid these complications. Give additional phosphate, potassium, magnesium, and thiamine, as well as a continuous supply of glucose to compen­sate for rapid shifts between ­intracellular and extracellular compartments (see Appendix for suggested recommendations). When refeeding is initiated, it should be performed in phases (see Section IV). Consider treating associated infections and likely micronutrient deficiencies.