Refeeding syndrome

Gowri1*, Ramya2

1Senior Staff Nurse, Kauvery Hospital, Salem, Tamil Nadu

2Staff Nurse, Kauvery Hospital, Salem, Tamil Nadu

*Correspondence

Abstract

A 3-month-old female infant born at 30 weeks’ gestation with extremely low birth weight (940 gram) was admitted with failure to gain weight and feed intolerance. The baby had a history of respiratory distress syndrome and medically managed necrotizing enterocolitis. During hospitalization, she developed persistent hypokalemia associated with renal tubular acidosis, abdominal distension, paralytic ileus and severe malnutrition. She was managed with electrolyte correction, nutritional rehabilitation, antibiotics, blood transfusions, and supportive care. The infant showed gradual clinical improvement and was discharged in stable condition.

Key words: Enterocolitis; Renal tubular acidosis; Hypokalemia

Introduction

Premature neonates with extremely low birth weight are at high risk for metabolic disturbances, feeding intolerance, growth failure, infections, and electrolyte imbalances. Persistent hypokalemia in neonates may result from gastrointestinal losses, inadequate intake, renal tubular disorder, or re-feeding syndrome. Early recognition and multidisciplinary management are essential to improve outcomes.

History

Demographic data

  • Age: 3 Month
  • Gender: Female
  • Gestational Age at Birth: 30 Weeks
  • Birth Weight:940gm
  • Twin 1
  • Delivered by Emergency LSCS

Present complaints

  • Failure to gain weight
  • Feed intolerance for 1 Month
  • Abdominal distension
  • Poor feeding

Past medical history

  • Received Surfactant therapy
  • Necrotizing Enterocolitis, medically managed
  • Prematurity

Relevant clinical findings

On admission

  • Pale and emaciated
  • Comfortable breathing on room air
  • Hemodynamically stable
  • Crt < 3seconds

Vital signs

Pulse rate146 b/m
Respiratory rate46b/m
Spo298%
TemperatureNormal

Systemic examination

CVSS1, S2 Heard, No Murmur
RespiratoryBilateral air entry present and clear
AbdomenMild abdominal distension
CNSActive and alert

Investigation

InvestigationResult
Hemoglobin7.3g/dl initially
Sodium129meq/l initially
PotassiumPersistent hypokalemia ( 2.4meq/l)
CRP6.7 mg/l
Blood groupingB positive

Serial Electrolytes

  • Sodium corrected from 129 to 139-140 meq/l
  • Potassium remained low despite correction measures

Additional Investigation

  • Urinary Electrolytes
  • Renal Function Test
  • Venous Blood Gas
  • Thyroid Profile
  • Cortisol Level
  • Serum Magnesium and Calcium

Ultra sonogram Finding

Ultra sonogram Abdomen

  • Normal Study
  • No structural abnormalities detected

Echocardiography: Normal

Barium Enema Study

  • Normal
  • No evidence of intestinal obstruction

Diagnosis

Final Diagnosis

  • Early Preterm (30 Weeks) Elbow Neonate
  • Severe Malnutrition / Failure to Thrive
  • Persistent hypokalemia is secondary to Renal Tubular Acidosis
  • Dyselectrolytemia
  • Feed intolerance
  • Paralytic Ileus
  • Anemia of Prematurity
  • History of NEC (medically managed)
  • Respiratory Distress Syndrome (resolved)

Medical Management

Nutritional Support

  • Feeds
  • Temporarily Withheld during severe abdominal distension
  • Gradual reintroduction of feeds
  • Paladai fmeding
  • Human Milk Fortifier (HMF)
  • MCT
  • Electrolyte correction
  • Potassium supplementation
  • Monitoring of Serum Electrolytes
  • Potassium -Sparing diuretic (Aldactone)

Infection Control

  • Inj. Colistin For 7days
  • Inj. Micafungin for 7 Days

Hematological Management

  • Three Units PRBC Transfusion
  • Darbepoetin Injection

Vitamin Supplementation

  • Thiamine
  • Vitamin D3
  • Zinc Supplements
  • Iron Supplementation

Supportive Care

  • Monitoring of vital signs
  • Fluid Electrolyte Balance
  • Nephrology consultation

Outcome

  • Electrolyte imbalance corrected gradually
  • Weight gain achieved
  • Feeding tolerance improved
  • Abdominal distension resolved
  • No further hepoglycemic Episodes
  • Clinically stable at discharge

Discharge Weight: 1.210kg

Discharge Plan

  • Paladai feeds 20-25ml every 3 hours
  • HMF 1/2 sachet each feed
  • MCT oil 0.5 ml each feed

Medications

  • Vitamin D3 drops
  • Domstal suspension
  • Zincovit drops
  • Ossopan d syrup
  • Tummy soft drops
  • Potklor syrup
  • Tasiron drops
  • Aldactone

Follow Up

  • CBC
  • Renalfunction Test
  • Darbepoetin
  • Urinary Electrolyte
  • Darbepoetin injection after one week
  • Vaccination as per schedule

Warning Sings

  • Breathing difficulty
  • Refusal of feeds
  • Lethargy
  • Vomiting

Discussion-Medical Aspects

This case highlights the complexity of managing ELBW preterm infants with multiple comorbidities. Persistent hypokalemia was the major clinical challenge and was attributed to renal tubular acidosis. Hypokalemia can lead to muscle weakness, paralytic ileus, poor feeding, and growth failure. The infant also demonstrated features suggestive of refeeding syndrome, a condition characterized by electrolyte shifts during nutritional rehabilitation. prompt identification and correction of electrolyte abnormalities, along with adequate nutritional support, resulted in successful recovery.

Prematurity, NEC, and prolonged hospitalization further increased the risk of metabolic complications and poor growth. Multidisciplinary involvement including neonatology, nephrology, nutrition, and nursing care was crucial in improving outcomes.

Discussion-nursing aspects

Nursing assessment

  • Continuous monitoring of vital signs
  • Assessment of feeding tolerance
  • Monitoring abdominal girth
  • Observation for dehydration and electrolyte imbalance

Nursing Intervention

  • Administer medications accurately
  • Monitor intake and output
  • Maintain strict aseptic precautions
  • Observe for signs of feeding intolerance
  • Monitor weight gain regularly
  • Educate parents regarding feeding techniques and medication administration

Parents’ education

  • Importance of follow-up visits
  • Recognition of warning signs
  • Proper administration of medications
  • Nutritional support and feeding schedule

Evaluation

  • Improved feeding pattern
  • Stable vital signs
  • Weight gain achieved
  • Electrolytes corrected
  • Successful discharge

Conclusion

This case demonstrates the successful management of a premature elbow infant with persistent hypokalemia due to renal tubular acidosis, feeding intolerance, and growth failure. Early diagnosis, aggressive electrolyte correction, and comprehensive nursing care contributed significantly to recovery. Close follow-up remains essential to ensure continued growth, developmental progress, and prevention of recurrent electrolyte disturbances.

Reference

  1. Wong’s Nursing care of Infants and children, 12th Edition
  2. The Hardy–Wilson classification

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