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02/08/2025

🔹Clinical Signs and Symptoms of Refeeding Syndrome
1️⃣ Hypophosphatemia
Cardiac: ↓ Stroke volume, hypotension, arrhythmias, heart failure.

Respiratory: Weak diaphragm, dyspnoea, respiratory failure.

Neurologic: Weakness, confusion, paraesthesia, seizures, coma.

Hematologic: Haemolysis, thrombocytopenia, leukocyte dysfunction.

2️⃣ Hypokalaemia
Cardiac: Arrhythmias, sudden death.

Respiratory: Respiratory muscle weakness, failure.

Neurologic: Weakness, paralysis.

GI/Muscle: Constipation, rhabdomyolysis, muscle necrosis.

3️⃣ Hypomagnesaemia
Cardiac: Arrhythmias.

Neurologic: Tremor, tetany, seizures, altered mental status, coma.

GI: Nausea, vomiting, diarrhoea.

Other: Refractory hypokalaemia/hypocalcaemia.

4️⃣ Thiamine (Vit B1) Deficiency
Encephalopathy, lactic acidosis, coma, death.

5️⃣ Sodium Retention / Fluid Overload
Pulmonary oedema, heart failure, impaired oxygenation.

6️⃣ Hyperglycaemia
Ketoacidosis, dehydration, impaired immune function.




02/08/2025

National Institutes for Clinical Excellence (NICE) Guidelines for Management of Refeeding Syndrome

1️⃣ When to Suspect/Refeeding Syndrome Risk (NICE criteria):
✅ High risk (any ONE of these):

BMI 15% in 3–6 months

No/LITTLE nutritional intake >10 days

Low baseline phosphate, potassium, or magnesium

✅ Moderate risk (any TWO of these):

BMI 10% in 3–6 months

No/reduced nutritional intake >5 days

History of alcohol/drug use (insulin, chemo, antacids, diuretics)

🧪 2️⃣ Electrolyte Targets & When to Treat
Hypophosphataemia (UK values):
Mild: 0.8–1.0 mmol/L

Moderate: 0.3–0.8 mmol/L

Severe:

02/08/2025

Refeeding Syndrome?
A potentially fatal condition in malnourished children when nutrition is restarted.

Insulin surge from carbohydrate intake causes a rapid intracellular shift of phosphate, potassium, and magnesium.

Leads to hypophosphataemia, hypokalaemia, hypomagnesaemia → can progress to coma, arrhythmias, heart failure, sudden death.

👶 Who is at Risk?
Anorexia nervosa and restrictive eating disorders

Chronic malnutrition: congenital heart disease, cancer

Malabsorption: inflammatory bowel disease, cystic fibrosis

Cerebral palsy with poor intake

Bariatric surgery or extensive bowel resections

Any child with prolonged starvation (>5–7 days)

Occurs with oral, NG, or parenteral feeding (TPN = highest risk)

🧪 UK Reference Values (SI Units):
Hypophosphataemia:

02/08/2025

In malnourished patients with anorexia nervosa, cases of refeeding syndrome have been documented during refeeding. Risk is greatest within the first 7 days of the start of feeding and is primarily indicated by serum hypophosphatemia (

02/08/2025

Early accounts of the syndrome were among starved survivors of wartime sieges and concentration camps and among prisoners of war when given sudden access to unlimited food. Refeeding syndrome occurs as a result of oral, enteral, or parenteral (highest risk) feeding of malnourished individuals, especially in the setting of aggressive refeeding.

02/08/2025

What is refeeding syndrome ?

02/08/2025

Always suspect inhalation injury in a child exposed to smoke in a closed space, with soot in the nose/mouth, singed hair, carbonaceous sputum, or altered consciousness.

Carbon monoxide (CO) poisoning is the most common toxic gas injury; it binds hemoglobin and prevents oxygen delivery, causing tissue hypoxia.

Carboxyhemoglobin (COHb) is measured with Arterial blood gas + co-oximetry (venous or arterial); pulse oximetry is unreliable because it reads falsely normal.

Treatment: Give 100% high-flow oxygen immediately (even before results) and continue until COHb 25% or there are neurological symptoms, consider hyperbaric oxygen therapy.

Always check for cyanide poisoning if there is unexplained metabolic acidosis, especially when synthetic materials burned.




02/08/2025

6. How should we treat Carbon Monoxide poisoning in children?

02/08/2025

5. What COHb level should we aim for during treatment?

02/08/2025

❓ 3. How is Carbon Monoxide measured in the blood?

02/08/2025

❓ 2. How does Carbon Monoxide (CO) poisoning cause hypoxia?

02/08/2025

❓ 1. How many types of inhalation injuries are there?

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