Refeeding syndrome in the critically ill pediatric patient: a pathophysiological approach
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Abstract
Introduction. Refeeding Syndrome (RS) is a potentially life-threatening metabolic complication triggered by the reintroduction of nutrition in pediatric patients with prolonged malnutrition or fasting. It results from an abrupt shift from a catabolic to an insulin-mediated anabolic state, causing rapid intracellular shifts of phosphate, potassium, and magnesium, along with thiamine deficiency, which may lead to multi-organ dysfunction. Children are particularly vulnerable due to limited energy reserves and higher metabolic demands. Objective. To provide an integrative pathophysiological overview of refeeding syndrome in critically ill pediatric patients, emphasizing risk identification, clinical manifestations, and evidence-based strategies for safe nutritional reintroduction. Methodology. A narrative review was conducted through PubMed, SciELO and ScienceDirect, including English and Spanish articles published between 2019 and 2024, with exceptional inclusion of earlier seminal studies. Controlled MeSH/DeCS terms related to “Refeeding Syndrome,” “Pediatric Nutrition” and “Malnutrition” were used. A total of 28 studies were selected based on clinical relevance and pediatric focus. Results. RS typically occurs within 48–120 hours after restarting nutrition, most frequently presenting as hypophosphatemia with associated electrolyte derangements and potential multi-organ impairment. Incidence reaches 7% in pediatric intensive care units and nearly 47% in children with severe malnutrition. Prevention relies on early risk stratification, close biochemical monitoring (every 6–8 h initially), hypocaloric initiation (10–12.5 kcal/kg/day), anticipatory thiamine supplementation and initiative-taking electrolyte replacement. Early, gradual enteral nutrition with adequate protein support (1–3 g/kg/day) is considered optimal. Conclusion. Refeeding syndrome in pediatric critical care demands initiative-taking, gradually titrated nutritional strategies and vigilant monitoring. Early detection and micronutrient correction are key to reducing morbidity and mortality. Further pediatric-specific prospective research is needed to refine metabolic risk-adapted protocols. General Area of Study: Health and Wellness. Specific area of study: Critical Care Medicine. Type of study: Bibliographic review.
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