- bismillah -
In both children and adults, the first step in the treatment of protein-energy malnutrition (PEM) is to correct fluid and electrolyte abnormalities and to treat any infections. The most common electrolyte abnormalities are hypokalemia, hypocalcemia, hypophosphatemia, and hypomagnesemia. Macronutrient repletion should be commenced within 48 hours under the supervision of nutrition specialists.
The second step in the treatment of protein-energy malnutrition (which may be delayed 24-48 h in children) is to supply macronutrients by dietary therapy. Milk-based formulas are the treatment of choice.
In the setting of malnutrition, risk of refeeding syndrome represents an additional clinical challenge.
Prolonged starvation followed by rapid feeding leads to refeeding syndrome (RS). RS involves resultant biochemical disturbance, physical symptoms, and physical signs. Insulin release leading to anabolic activity underlies the pathophysiology of RS. Feeding overwhelms the dearth of electrolytes and micronutrients. This effect disrupts cellular function. Tissue edema, hypophosphatemia and pathological fluid shifts define RS. RS was identified in 4% of cases of parenteral nutrition (PN) in a UK study while physicians only recognized it half the time. A study in New Zealand also shows similar data. RS remains underrecognized. PN patients are considered to be at high risk and using protocols with slower and lower rates of refeeding reduces deaths attributable to RS.
RS can also occur in patients who are replenished with food, vitamins and electrolytes after suffering from anorexia nervosa (AN).
Other groups at risk for RS include alcoholics undergoing detoxification, extremely-low-birth-weight neonates who were intrauterine growth-restricted, cancer patients who have suffered from cachexia, and adults with kwashiorkor who get enteral rather than parenteral feeding.