Paeds · gastroenterology-hepatology-and-nutrition
Parenteral nutrition and refeeding syndrome
Also known as Parenteral nutrition · Total parenteral nutrition · TPN · Refeeding syndrome · Refeeding hypophosphataemia · Intestinal failure-associated liver disease · IFALD · Parenteral nutrition-associated cholestasis · PNAC · Parenteral nutrition-associated liver disease
Fellowship guide to prescribing parenteral nutrition safely in children and to preventing refeeding syndrome when nutrition is restarted after starvation. The page covers the rule that the gut should be fed first and parenteral nutrition reserved for when it cannot, the four parenteral streams of glucose given as a glucose infusion rate, amino acids, lipid and electrolytes with trace elements, how to build the bag to an infant target of around 90 to 120 kcal per kilogram per day, the complications of metabolic disturbance, catheter sepsis and intestinal failure-associated liver disease, and the refeeding principle that a starved child restarted on nutrition needs thiamine, conservative starting calories, and correction and monitoring of phosphate, potassium and magnesium.
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- A starved or malnourished child who is restarted on feeding, whether enteral or parenteral, can develop refeeding syndrome within 72 hours, and the first sign is often a falling phosphate, potassium or magnesium with fluid overload and cardiac failure
- A rising conjugated bilirubin in an infant on parenteral nutrition for over two weeks is intestinal failure-associated liver disease until proven otherwise, and a high sustained lipid load plus recurrent sepsis are the two modifiable drivers
- A glucose infusion rate that exceeds the childs maximal glucose oxidation capacity causes hyperglycaemia, osmotic diuresis and hepatic lipogenesis rather than nourishment
- A fever in a child with a central venous catheter is a line infection until blood cultures prove otherwise, because catheter-related bloodstream infection is the commonest acute threat to the child on parenteral nutrition
- A malnourished child must never be rehydrated and refed rapidly, because the sodium and fluid retention of the insulin surge can precipitate acute heart failure before the electrolytes have even been measured
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- Indications for parenteral nutrition in children
- Composition of parenteral nutrition and the glucose infusion rate
- Refeeding syndrome definition, risk factors and prevention
- Intestinal failure-associated liver disease pathogenesis and lipid strategy
- Stepwise parenteral nutrition prescription and monitoring
- Catheter-related bloodstream infection prevention
- The malnourished adolescent restarted on feeding and refeeding syndrome
- The preterm infant on parenteral nutrition with rising conjugated bilirubin
- The child with a central line and fever
- Long case: a child on home parenteral nutrition
- Short case: prescribing and monitoring parenteral nutrition on the ward
- Nutrition: parenteral nutrition and refeeding syndrome
- Gastroenterology: parenteral nutrition-associated liver disease
- Composition and complications of parenteral nutrition
- Refeeding syndrome biochemistry and management
- Prevention of intestinal failure-associated liver disease
- Assessment and long-case discussion of a child on parenteral nutrition
- Parenteral nutrition and refeeding syndrome
- Parenteral nutrition-associated liver disease
- Central line complications in the child on parenteral nutrition
- Patient Care: safe prescription and monitoring of paediatric parenteral nutrition
- Medical Expert: parenteral nutrition and refeeding syndrome in children
Overview & Definition
Picture a premature baby whose gut is too immature to absorb milk, hanging a bag of parenteral nutrition from a central line and growing on it for weeks. Picture a malnourished adolescent with anorexia nervosa admitted for refeeding, whose phosphate crashes on day two. These two children sit at the heart of this topic, and they share one governing idea: nutrition saves starved children, but nutrition delivered the wrong way can kill them. Parenteral nutrition is the intravenous delivery of nutrients when the gut cannot be used, and refeeding syndrome is the metabolic collapse that follows when nutrition is reintroduced too quickly to a starved body. [3] [5]
The vocabulary must be held precisely because examiners trade in it. Parenteral nutrition delivers fluid, glucose, amino acids, lipid, electrolytes, vitamins and trace elements directly into the bloodstream, bypassing the gut entirely. Total parenteral nutrition means the regimen supplies all of the childs nutritional needs; partial parenteral nutrition supplements what the gut can still absorb. The older abbreviation TPN still appears on wards, but the modern term is simply parenteral nutrition. [3]
Refeeding syndrome is defined by the biochemical and fluid disturbances that appear when carbohydrate is reintroduced to a starved patient. The hallmark is a fall in serum phosphate, potassium and magnesium within the first 72 hours, driven by an insulin surge that pushes these ions into the cells, accompanied by thiamine depletion and sodium and fluid retention that can precipitate cardiac failure. It is not a rare curiosity; it is a predictable consequence of feeding the starved child too fast, and the prevention is entirely in the prescribers hands. [5] [6]
The governing principle of management, then, is to reserve the parenteral route for genuine gut failure, to build the bag carefully around the four nutrient streams, to protect the central line and the liver, and to treat every starved child as a refeeding risk before the first calorie goes in. [3] [5]
References12ShowHide
- [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
- [4]van Goudoever JB; Carnielli V; Darmaun D; et al ESPGHAN/ESPEN/ESPR/CSPEN guidelines on pediatric parenteral nutrition: Amino acids. Clin Nutr, 2018.PMID 30100107
- [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
- [7]Runde J; Sentongo T Refeeding Syndrome. Pediatr Ann, 2019.PMID 31710364
- [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
- [10]Pironi L; Sasdelli AS Intestinal Failure-Associated Liver Disease. Clin Liver Dis, 2019.PMID 30947877
- [11]Wang N; Yan W; Hong L; et al Risk factors of parenteral nutrition-associated cholestasis in very-low-birthweight infants. J Paediatr Child Health, 2020.PMID 32100397
- [12]Norsa L; Goulet O; Alberti D; et al Nutrition and Intestinal Rehabilitation of Children With Short Bowel Syndrome: A Position Paper of the ESPGHAN Committee on Nutrition. Part 1: From Intestinal Resection to Home Discharge. J Pediatr Gastroenterol Nutr, 2023.PMID 37256827