Incidence of refeeding syndrome and its associated factors in South African children hospitalized with severe acute malnutrition

Background: The judicious use of the world health organization (WHO) guidelines in the management of severe acute malnutrition (SAM) is very crucial in avoiding complications. We investigated the incidence of refeeding syndrome and its associated factors in children under 5 years with SAM receiving treatment as inpatients. Methods: A prospective study of 104 children with SAM admitted to the paediatric unit of Dr George Mukhari Academic Hospital (a teaching hospital in Pretoria, South Africa) since March 2014 to March 2015 was conducted. On admission, history on socioeconomic status and co-morbidities, a comprehensive clinical examination, and anthropometric measurements were obtained. All the patients were managed using the 10 steps of management of malnutrition with cautious feeding and broad spectrum antibiotics being instituted. Bloods were taken for calcium, magnesium, phosphorous, urea, and electrolytes on admission and compared to repeat bloods done on day 5 post admission. Results: There were a total of 46 (44%) females. The mean age was 16 months with a mean weight-for-height Z-score of -2.15 ± 1.87. The majority 63% (63/104) of the children had oedematous SAM. There was an HIV infection rate of 33% (35/104). The incidence of refeeding syndrome was 16/104 (15%). Refeeding syndrome was strongly associated with the following medical complications: diarrhoea 81% (13/16), shock 25% (4/16), and hypokalaemia 81% (13/16) (P value < 0.01). Admission potassium and phosphorus were strongly associated with refeeding syndrome with a mean of 3.04 ± 1.16 for potassium and 1.14 ± 0.39 for phosphate (P value < 0.05). Refeeding syndrome was also strongly associated with hypophosphataemia (0.65 ± 0.28), hypocalcaemia (2.34 ± 0.24), and hypomagnesaemia (0.91 ± 0.52) on day 5 repeat bloods (P value < 0.0001). Conclusions: The complication of refeeding syndrome is a major problem that occurs with the reintroduction of feeding in children with severe acute malnutrition. This detrimental complication can be avoided by practices that promote cautious feeding, and as well, clinicians being vigilant in detecting the complication in all children with severe acute malnutrition.