Prevention of refeeding syndrome: Evaluation of an enteral refeeding protocol for severely undernourished children

Abstract

Objectives: Refeeding syndrome (RS) defines the deleterious clinical and metabolic changes occurring during nutritional support of severely malnourished patients. Pediatric guidelines to prevent and treat RS are scarce and highly variable. This study aimed to evaluate the effectiveness and safety of an enteral refeeding protocol in severely undernourished hospitalized children with anorexia nervosa (AN) or organic diseases (OD).

Methods: This ancillary study to the Preventing Malnutrition and Restoring Nutritional Status in Hospitalized Children (PREDIRE) trial (NCT01081587), included severely undernourished children hospitalized between January 2010 and June 2018 and treated with an enteral refeeding protocol drafted for the study. The effectiveness was assessed by weight gain and safety by clinical and laboratory abnormality occurrence over the initial 3-week refeeding period, which represents the most critical period for the development of RS.

Results: After 3 weeks of refeeding, the mean weight for height ratio increased from 72% to 82%, and half of the patients with severe undernutrition improved their nutritional status. The prevalence of RS was 10.4%. No clinical cardiac or neurological complication occurred. The most frequent laboratory complication was hypophosphatemia in 13.7% of patients; but symptomatic in only two patients (2.5%). Compared with patients with OD, patients with AN improved their weight-for-height ratio faster without significantly more frequent complications, except for hepatic cytolysis which was less prevalent in AN (8.3% vs. 36.8%).

Conclusions: The proposed enteral refeeding protocol appears safe for treating severely undernourished children of different etiologies, with a low prevalence of RS and half of the patients recovered from severe malnutrition within a 3-week period.

Keywords: adolescent; anorexia nervosa; enteral nutrition; hypophosphatemia; malnutrition.

Figure 1

Flowchart. PREDIRE, Preventing Malnutrition and Restoring Nutritional Status in Hospitalized Children.

Figure 2

Evolution of the weight for height ratio during the refeeding protocol. WHR was significantly lower in children with AN than in children with OD at admission (p = 0.023) and at Day 7 (p = 0.023). At Days 14 and 21, there was no significant difference between both groups. During the 3‐week refeeding protocol, the improvement in WHR was higher in children with AN than in children with OD. AN, anorexia nervosa; OD, organic disease; WHR, weight for height ratio.