Refeeding syndrome characterised by hypophosphataemia in children 0 – 59 months diagnosed with severe acute malnutrition in a South African setting

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Fourie, Natalie
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University of the Free State
Background and motivation: The World Health Organisation (WHO) uses the term severe acute malnutrition (SAM) to describe children under five years who are severely malnourished and present with severe wasting, classified by weight-forlength/height <-3 standard deviation (SD) according to the WHO growth standards or mid-upper arm circumference (MUAC) <11.5 cm, or bilateral pitting oedema. Children with complicated SAM require hospitalisation and urgent care including nutritional intervention. Too rapid introduction of nutrition can result in refeeding syndrome (RFS), a life-threatening complication with onset usually within five days of starting nutritional therapy. Yet, RFS remains underdiagnosed because a universally agreed definition does not exist, and many physicians are unaware of the syndrome. Moreover, current WHO guidelines for the dietary treatment of SAM, and published guidelines for the prevention of RFS in the clinical setting, are incongruent. Very few studies to date have investigated the incidence of RFS in SAM, particularly in relation to a high prevalence of human immune deficiency virus (HIV). This study, therefore, aimed to identify the incidence of RFS, as well as factors that may be associated with the onset of RFS, among children with SAM in a South African public health setting. Methods: A retrospective analytical cohort study of children aged 0 – 59 months admitted with SAM to Rahima Moosa Mother and Child Hospital, Johannesburg, from 1 October 2014 to 31 December 2018, was conducted. Among the hospital files that could be retrieved from the archives, the diagnosis of SAM according to the WHO definition was confirmed for 126 files. In these participants, the occurrence of RFS, as characterised by a drop in blood phosphate levels by >0.16 mmol/L to a level <0.65 mmol/L, was noted. Biochemical and clinical features on admission, as well as dietary intake, were compared between participants who developed RFS and those who did not, using Fisher’s exact, Chi-square or Kruskal-Wallis tests as appropriate. P-values <0.05 were considered statistically significant. Results: The incidence of RFS in the sample (63% male; median age: 34 months) was 8.7% (n=11) of whom 18.2% died. The development of RFS was statistically significantly associated with hypophosphataemia, hypokalaemia, hyponatraemia, dehydration, international normalised ratio (INR) >1.7, and urinary tract infection (UTI) on-admission, and longer length of hospitalisation, but not with being HIV positive. HIV-exposure was, however, borderline statistically significant and diarrhoea had a trend towards significance on admission in participants who later developed RFS. Findings on protein and energy intakes were inconclusive as the grade of oedema, which influences the dietary requirements, was not recorded consistently in the hospital files. Most participants developed RFS after day five of hospitalisation, which is inconsistent with the usual timing of the development of RFS. Most participants were receiving F-75 substitutes (standard, soy or extensively hydrolysed infant formula with or without additional modular supplementation) during the initial phase of dietary treatment, thus high protein intake in oedematous participants may have contributed to the development of RFS in this study. Conclusions and recommendations: This study confirms the occurrence of RFS in patients with SAM and identifies several biochemical and clinical features present on admission that may aid in the identification of high-risk patients. This information may assist in the revision and standardisation of feeding protocols. Further investigation into risk factors which might predispose a child with SAM to develop RFS may help in reducing the incidence of RFS and the concurrent risk of death that it poses and, therefore, assist with the WHO’s goal to reduce the mortality of children under the age of five. Physicians, nurses and dietitians should be educated on RFS in order to diagnose and treat patients with SAM more effectively. The study highlights the importance of identifying and recording the grades of oedema in children with complicated SAM, which is vital for prescribing the correct dietary requirements. It also highlights the need for dietitians and other healthcare professionals to follow the WHO guidelines for the treatment of SAM, and use F-75 substitutes with great caution as their protein content is higher and their micronutrient composition is lower compared to F-75.
Dissertation (M.Sc. (Dietetics))--University of the Free State, 2020, Refeeding syndrome, Severe acute malnutrition, Hypophosphataemia, Oedema, Malnutrition, Paediatrics, Energy intake, Protein intake, Refeeding syndrome risk factors, South Africa