Parenteral nutrition and refeeding syndrome — formative SAQs

Two formative SAQs on parenteral nutrition and refeeding syndrome in children: a malnourished adolescent with anorexia nervosa admitted for refeeding, testing refeeding risk, the insulin-driven biochemistry, thiamine and conservative starting calories and the daily monitoring of phosphate, potassium and magnesium; and a premature infant on long-term parenteral nutrition with a rising conjugated bilirubin, testing the composition streams, the glucose infusion rate, the prevention of intestinal failure-associated liver disease and the lipid strategy.

Prompt

Parenteral nutrition and refeeding syndrome

SAQ 1 — The malnourished adolescent restarted on feeding (10 marks, 15 minutes)

A 15-year-old girl with anorexia nervosa is admitted for refeeding after six weeks of negligible intake and a 15 per cent weight loss. Her body mass index is 15. On day two of a refeeding regimen the phosphate has fallen, she is oedematous, and her heart rate is rising. [5]

a) Define refeeding syndrome and explain the biochemical mechanism by which restarting carbohydrate drives phosphate, potassium and magnesium into the cell and depletes thiamine. (3 marks) [5] [6]

b) Identify the features in this history that place her at high risk of refeeding syndrome, using the ASPEN consensus risk stratification. (2 marks) [5]

c) Outline the prevention and management you should have instituted before and during refeeding, naming thiamine, conservative starting calories, and the correction and monitoring of phosphate, potassium and magnesium. (3 marks) [5] [6]

d) Explain why she has become oedematous with a rising heart rate, and state the immediate response. (2 marks) [6]

Paediatrics Fellowship Pro

You have read the opening of this SAQ. The complete unit — every section and its primary-source references — is part of the Paediatrics Fellowship fellowship atlas.

References7Show ledger

[1]Joosten K; Embleton N; Yan W; et al ESPGHAN/ESPEN/ESPR/CSPEN guidelines on pediatric parenteral nutrition: Energy. Clin Nutr, 2018.PMID 30078715
[2]Lapillonne A; Fidler Mis N; Goulet O; et al ESPGHAN/ESPEN/ESPR/CSPEN guidelines on pediatric parenteral nutrition: Lipids. Clin Nutr, 2018.PMID 30143306
[3]Mihatsch WA; Braegger C; Bronsky J; et al ESPGHAN/ESPEN/ESPR/CSPEN guidelines on pediatric parenteral nutrition. Clin Nutr, 2018.PMID 30471662
[5]da Silva JSV; Seres DS; Sabino K; et al ASPEN Consensus Recommendations for Refeeding Syndrome. Nutr Clin Pract, 2020.PMID 32115791
[6]Corsello A; Trovato CM; Dipasquale V; et al Refeeding Syndrome in Pediatric Age, An Unknown Disease: A Narrative Review. J Pediatr Gastroenterol Nutr, 2023.PMID 37705405
[8]Lee WS; Chew KS; Ng RT; et al Intestinal failure-associated liver disease (IFALD): insights into pathogenesis and advances in management. Hepatol Int, 2020.PMID 32356227
[9]Fundora J; Aucott SW Intestinal Failure-Associated Liver Disease in Neonates. Neoreviews, 2020.PMID 32873652