Refeeding syndrome in pediatric acute care patients: a brief report of pediatric dietitians’ practice

Introduction

Refeeding syndrome (RFS) is a potentially life-threatening condition that can occur in malnourished individuals who resume feeding suddenly (1). In pediatric populations, RFS’s constellation of biochemical and clinical signs can lead to life threatening complications (2). Risk factors for developing RFS are severely malnourished children with starvation physiology (3). The incidence of RFS varies between 0–80% depending on definitions used (4) and has been associated with a significantly increased 6-month mortality among malnourished individuals (5), highlighting the importance of recognising RFS in pediatric patients to prevent life-threatening complications.

Despite the long-standing recognition of RFS as a mechanism for potential serious complications of nutritional intervention, high quality scientific evidence regarding the clinical syndrome is lacking. There is currently no universal recommendation for how to advance the nutritional regimen in a safe way. Many available recommendations are general and vague, providing advice such as ‘increase slowly’ (6), ‘advance gradually’ (4) or ‘provide modest energy increases’ (7). Not only is the literature inconclusive but reintroducing nutrition at a low rate with slow advancement may be at odds with the nutritional rehabilitation desired in at risk populations (8).

Reporting on RFS has focussed mainly on patients diagnosed with eating disorders or adults’ patients who are severely malnourished (8). The incidence of RFS and identifying characteristics remains problematic mainly due to inconsistencies in the definitions used (8). These challenges make a comprehensive comparison of different study populations difficult and hinder the development of evidence-based management protocols, resulting in continued reliance on expert opinion (8).

The American Society for Parenteral and Enteral Nutrition’s (ASPEN) 2020 consensus recommendations (8) were the first in literature to provide guidance on management of RFS in acutely ill pediatric patients. This study aimed to determine if it was feasible to collate, via an online survey, pediatric dietitians’ practice, in identifying and managing RFS and compare ASPEN’s consensus recommendation publication (8). We present this article in accordance with the SURGE reporting checklist (available at https://pm.amegroups.com/article/view/10.21037/pm-25-159/rc).

Methods

A cross-sectional online survey was conducted by inviting UK (United Kingdom)-based pediatric dietitians to participate. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. Faculty Research Ethics and Integrity Committee of University of Plymouth, granted this study ethical approval on 16 March 2021 [Plymouth Ethics Online System (PEOS) approval code: 2590]. Informed consent was obtained from all individual participants. A pre-designed survey, consisting of 30 questions, was used in this study, see Table 1. The survey assessed the individual dietitians’ experience of RFS using the ASPEN definition (8) and collated results on all aspect of RFS including classification, assessment, management, and monitoring. Prior to launch the survey was peer reviewed and piloted to assess face validity, time taken to complete and potential sources of bias (9). Feedback was implemented and the survey administered using Jisc Online Surveys^TM between April and May 2021.

Registered pediatric dietitians working in the acute services at specialised tertiary pediatric hospitals and secondary pediatric services within district general hospitals (DGH) in the UK were eligible to participate. A social network site (SNS) distribution strategy was chosen due to the limitations on non-coronavirus disease (COVID)-related research activities in the National Health Service (NHS) set by the Health Regulations Authority (HRA) during the SARS-CoV-2 pandemic. Respondents were recruited through members only Facebook^® pages of the British Dietetic Association and Twitter^® with convenience sampling using professional networks of the researchers. The survey remained open for 6 weeks with reminders posted to social media at weeks two and four, respectively. No incentives were offered to complete the survey. Consent was obtained on submission of a completed survey. Feasibility was assessed by (I) examining the recruitment yield of pediatric dietitians working in acute care settings; (II) representation across multiple tertiary pediatric hospitals; and (III) completeness of survey responses, including item-level response rates. These outcomes were used to evaluate the practicality and limitations of SNS-based recruitment for informing future large-scale studies of pediatric RFS management.

Quantitative and descriptive analyses were performed on the survey data. Nominal data (free-text responses) were grouped and classified into categories. Frequency and relative distribution were calculated. Inferential statistics were considered however acknowledging low response rates were inadequate in terms of statistical power.

Results

A summary of this survey’s results, with comparison to ASPEN Consensus Recommendations (8) is shown in Table 2. The ‘survey Respondents’ column has the percentage of respondents whose practice is in keeping with the ASPEN Consensus Recommendations (8), the range offered by all respondents and the most common response.

Despite a combined engagement, from the three social media posts of 1,765 only 37 attempted to complete the survey. Twenty respondents were screened out at the eligibility stage, as they did not meet the inclusion criteria, resulting in 17 completed surveys [England (53%), Scotland (41%), and unknown (6%)]. Nine of 27 tertiary pediatric hospitals in the UK were represented. Five respondents worked in secondary pediatric services, within a DGH. Four respondents worked in the same tertiary pediatric hospital. Respondents were asked to consider the RFS definition suggested in ASPEN Consensus Recommendations (8) and if they had experienced RFS based on this. There was variability in respondents’ experience with RFS (Table 3, column 2). Overall, fifteen (88%) of respondents reported treating a patient at risk of RFS; one (6%) reporting identification of patients at risk weekly within their specialty versus one (6%) reported once in their 12-year career. Ten (62%), respondents reported patients presenting at risk RFS was rare in their clinical practice.

To identify patients the ASPEN recommendations, offer three risk categories: ‘mild risk’, ‘moderate risk’ and ’significant risk’ (8). Sixteen 94% respondents reported using risk categories, however terminology varied. Eight respondents (47%) classified patients into mild, moderate, and high-risk categories. One respondent (6%) reported using ‘at risk’, ‘at high risk’, and ‘at extremely high risk’. One respondent (6%) reported using no classification categories.

All seventeen respondents (100%) reported using nutritional intake as an indicator of risk. ASPEN recommendations suggest 3–7 or more days depending on risk category. Survey respondents reported, most commonly, a limited intake for 5 days or more to indicate risk (range 4–14 days).

Sixteen respondents (94%) also used weight loss as opposed to weight for length z-scores as recommended by ASPEN. Fourteen (82%) respondents use serum electrolytes and high risk co-morbidities both of which are in-keeping with ASPEN’s recommendations. No respondents reported using loss of subcutaneous fat or loss of muscle mass to identify risk. Table 3 details the individual responses by each respondent.

To manage patients at risk of RFS, seventeen respondents (100%) reported using intravenous (IV) fluids in patients. Eight respondents (47%) would modify glucose concentrations. ASPEN make no recommendation regarding use of IV fluids other than to specify that calories provided should be included in nutritional calculations. Three (18%) respondents, who use IV fluids, would also modify sodium concentrations. ASPEN make no recommendations regarding sodium restrictions. Table 4 details respondents management strategies.

To initiate nutrition ASPEN, recommend 40–50% goal. Seventeen respondents (100%) reported reducing starting rates for enteral and parenteral nutrition in patients at risk of RFS. Fourteen (82%) would reduce to 25–50% of calculated requirement when using estimated average requirement (EAR) to identify need. Three respondents (18%) calculated nutritional requirement using basal metabolic rate (BMR), which is lower than EAR, and started nutrition at 50–100% of BMR. Seventeen respondents report increasing nutrition over 4 days on average (range 3–10 days).

Supplementation of vitamins and minerals was commenced prophylactically by fifteen (88%) respondents. ASPEN recommend at least 5–7 days of thiamine supplementation and to add injectable multivitamins to parenteral nutrition solutions.

In terms of monitoring, ASPEN suggest vital signs every 4 hours, monitoring serum electrolytes 12 hourly for the first 3 days, daily weights, and cardiorespiratory monitoring for unstable patients as per routine standards of care (8). Survey respondents reported the following for monitoring purposes; fourteen (82%) use early warning observations, such as Pediatric Early Warning System (PEWS), seventeen (100%) reported using serum electrolytes however only ten (60%) respondents reported that the serum electrolytes requested, would be checked by the clinical team. Reasons reported in this study for not checking serum electrolytes included consultant decision, lack of understanding of refeeding problems by the clinical team, staff not following the guideline, and initial results being within reference range. Weight was used to monitor patients by fourteen (82%) respondents.

Discussion

This feasibility study demonstrated it was possible to survey the management strategies used by pediatric dietitians, working in either specialised tertiary pediatric hospitals or secondary pediatric services in the UK. However, participation was limited.

Convenience sampling was employed in this study targeting members of the pediatric specialist subgroup of the British Dietetic Association, the national professional body of dietitians in the UK. Owing to the SARS-CoV-2 pandemic, the HRA paused all non-COVID-related research activities in the NHS. This study was therefore undertaken using a social media recruitment strategy, aiming to capture the interests of pediatric dietitians during their non-working time. It is reported in literature that 80% of UK registered dietitians considered themselves social media users with 41% using it for professional reasons (10). A further study involving the Dietitian’s Association of Australia found similar results with 37.5% of respondents using social media for professional reasons (11). Seventeen respondents accessed this survey via social media platforms. Ideally each, of the 27 identified, specialist tertiary pediatric hospitals, within the UK would have been represented in the survey. Consequently, the findings primarily reflect individual clinical practice and may indicate emerging trends, rather than being generalisable to the wider pediatric dietetic population. Due to the specialist nature of the topic, the restrictions on non-COVID-related research by the HRA and a social media distribution strategy, the response rate was reasonable for a feasibility study. A higher response rate is, however, needed to truly identify management of RFS in pediatric populations amongst pediatric dietitians. A structured interview, with an identified, experienced, practitioner from each tertiary pediatric centre in the UK would have potentially, yielded more robust results but this was not possible during the SARS-CoV-2 pandemic.

The absence of a universally accepted definition for RFS makes it challenging to assess how often it occurs in pediatric patients. Using the definition suggested by ASPEN Consensus Recommendations (8) yielded variable results. It is unclear why there is such variation however the dietitian’s clinical area may impact on the frequency of RFS, with those working in gastrointestinal or oncological conditions potentially identifying RFS more frequently.

To identify patient’s consensus was achieved with all respondents using reduced nutritional intake as a marker of risk for RFS. However, discord existed amongst our respondents in the duration of reduce nutritional intake that would contribute to RFS risk.

When assessing weight loss, there are subtle differences between our dietitian survey respondents practice and ASPEN Consensus Recommendations (8). Our respondents, who use weight loss to support identification of patients at risk, use percentage of weight lost while ASPEN recommendations percentage of ‘normal for expected weight gain’ (8). Normal for expected gain aims to capture those that are chronically growth restricted, as opposed to those who have suffered weight loss. This subtle difference requires consideration as in the absence of historical anthropometric measurements, which is often a factor in acutely, unwell children, weight loss is easier to determine than normal for expected gain. It will be interesting to observe if there is a shift from weight loss to normal for expected gain due to the consensus recommendations of ASPEN.

Loss of subcutaneous fat and loss of muscle mass were included in ASPEN Consensus Recommendations (8) for both adult and paediatric patients at risk. However, understanding of both in paediatric patients is limited, with likely extrapolation from adult data which may not be directly translatable (12)^. Methods to measure loss of subcutaneous fat and muscle mass include imaging methods that are expensive, specialised and could expose patients to radiation, ultrasonography, mid-upper arm circumference or skinfold thickness which are inexpensive, bedside measures however can be operator dependent (12). This study did not specifically ask respondents about methods to measure loss of subcutaneous fat, or loss of muscle mass however there was a free text opportunity to add any additional assessment data. Respondents acknowledged that they would consider all intracellular cations in combination rather than any one in isolation. Hypophosphatemia is often considered the hallmark of RFS yet, more common causes include sepsis, stress (postoperative, trauma, thermal injury), pharmacological therapy (insulin, chemotherapy, or diuretics), and kidney failure (13). It, therefore, remains challenging to use serum electrolytes in isolation to diagnose RFS and a holistic approach, including nutritional assessment, should be considered. It is also noteworthy that serum electrolytes may be normal, despite total-body deficiency, when RFS ensues so attention to other risk factors is important (8). Many respondents also considered high risk co-morbidities in their assessment of risk commonly quoting malabsorptive conditions, such as inflammatory bowel disease and short bowel syndrome, or oncological conditions. ASPEN Consensus Recommendations classify high risk co-morbidities states as ‘mild’, ‘moderate’, or ’severe’ (8). This classification system may be open to interpretation depending on the clinical experience of the dietitian. For example, what may be a mild disease state to a tertiary pediatric hospital may be considered more moderate or severe in a DGH with a pediatric ward. Interestingly alcohol abuse was reported as a potential cause of RFS which might be unexpected in pediatric populations. It is plausible to suggest that guidance is a shared adult and pediatric population guideline. That said, the UK was found to have a higher prevalence of underage alcohol use (14) so this might reflect adolescent cases. Pharmacological treatment, such as insulin, chemotherapy, antacids, or diuretics was also reported as an indicator of RFS. These therapies are more likely to cause hypophosphatemia (8) and is an example of the confusion that can exist in identifying RFS.

Our respondents report reducing starting rates of nutrition when managing RFS based on the degree of risk identified. This is in contrast with ASPEN Consensus Recommendations which has three risk classifications yet only one approach in the management section of their algorithm (8). It could be argued that the significance of quantifying the degree of risk is debatable when the management is the same, regardless of the identified level of risk. The challenge is identifying if this hinders patient’s nutritional rehabilitation by being overly cautious or if it is the safest and most appropriate management, particularly for patients with a higher degree of risk. An assertive feeding protocol would advance nutrition rates quickly to optimise nutritional status and ongoing recovery for the patient (15). However, previous studies examining the impact of this approach have focused on patients diagnosed with eating disorders (15) which, with isolated starvation, makes it challenging to draw comparisons with acutely, ill pediatric patients. Conversely, judicious nutrition rates have been studied in the critically ill population however based solely on hypophosphatemia within 72 hours of initiation of nutrition (15). In the critically ill population hypophosphatemia could be due to the underlying condition (16). The optimal initiation rates for nutrition, in the acutely ill population at risk of RFS, remains unknown and further studies would be beneficial.

There was a disconnect about how often serum electrolytes should be monitored; respondents request daily in clinical practice with ASPEN Consensus Recommendations suggesting 12 hourly initially (8). In reported practice, requests for daily serum electrolytes were not actioned by the managing clinical team highlighting a lack of awareness of RFS problems.

Our study was limited by a small sample size, recruited solely via SNS-based dissemination, which may limit representativeness of the wider pediatric dietetic community. However, representation from 9 of 27 specialised tertiary pediatric hospitals in the UK, were included. RFS can be considered a multiprofessional concern so there is a risk of selection bias by only approaching dietitians to participate in the study. Our study was conducted during the global SARS-CoV-2 pandemic limiting recruitment of our respondents. A follow-on study recruiting survey respondents through individual children’s hospital or professional association would ascertain UK pediatric dietitians’ practice. Our methodology limited this study’s ability to explore duration of micronutrient supplementation.

Conclusions

Pediatric dietitian survey respondents reported many consistencies in managing patients at risk of RFS, with ASPEN Consensus Recommendations (8). Differences did exist amongst our respondents highlighting the challenges in managing RFS in pediatric patients, which is a relatively rare disorder. This feasibility study demonstrated that it was possible to survey pediatric dietitians working across specialised tertiary pediatric hospitals and secondary pediatric services in the UK regarding their management strategies for RFS. However, feasibility outcomes indicate that reliance on social networking site-based recruitment alone may limit participation and representativeness. Future large-scale national surveys are therefore likely to require supplementary recruitment strategies, such as targeted professional networks or institutional dissemination, to optimise reach and engagement.

Acknowledgments

The authors would like to extend their thanks to all the paediatric dietitians who generously gave their time to contribute to this study, taking time away from their clinical workloads in a time of great adversity. We thank Dr. Milly Lo and Dr. Laura Smith for their expertise, guidance, and support with preparing this manuscript.

Footnote

Reporting Checklist: The authors have completed the SURGE reporting checklist. Available at https://pm.amegroups.com/article/view/10.21037/pm-25-159/rc

Peer Review File: Available at https://pm.amegroups.com/article/view/10.21037/pm-25-159/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://pm.amegroups.com/article/view/10.21037/pm-25-159/coif). J.H.C. has received grant funding from the British Dietetic Association General education Trust Fund, Matthews Friends and speaker honoraria and grant funding from Nutricia^®. J.H.C. is also a member of the International Medical Board for Matthew’s Friends Charity and the Director and CEO of own limited company—The Keto Dietitian. The other author has no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. Faculty Research Ethics and Integrity Committee of University of Plymouth, granted this study ethical approval on 16 March 2021 [Plymouth Ethics Online System (PEOS) approval code: 2590]. Informed consent was obtained from all individual participants.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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