GENERALIDADES Presencia de malnutrición seguida de realimentación enteral o EV en niños y adultos que predispone a alteraciones de fluidos y electrolitos.
Síndrome bien descrito en adultos y en niños, sin embargo, en la
población neonatal se cuenta con literatura limitada.
ASPEN 2020: Describe criterios diagnósticos para niños, asi como
recomendaciones, mas no hay recomendaciones específicas para neonatos
Cormack BE, Jiang Y, Harding JE, Crowther CA, Bloomfield FH; ProVIDe Trial Group. Neonatal Refeeding Syndrome and Clinical Outcome in Extremely Low-Birth-Weight Babies: Secondary Cohort Analysis From the ProVIDe Trial. JPEN J Parenter Enteral Nutr. 2021;45(1):65-78. DEFINICIÓN ASPEN 2020: Reducción de concentración de fósforo, potasio y/o magnesio, o tiamina, que se desarrolla horas o días luego de inicio de ingesta de calorías posterior a un periodo de malnutrición
Ichikawa 2012 • Hypophosphatemia in small for gestational age extremely low birth weight infants receiving parenteral nutrition in the first week after birth.
Moltu 2013 • Enhanced feeding in very-low-birth-weight infants may cause electrolyte
disturbances and septicemia-a randomized controlled trial.
Bonsante 2013 • Initial amino acid intake influences phosphorus and calcium homeostasis in preterm infants. It is time to change the composition of the early parenteral nutrition
Berna 2015 • Early hypophosphatemia in preterm infants receiving aggressive parenteral
nutrition
Cormack BE, Jiang Y, Harding JE, Crowther CA, Bloomfield FH; ProVIDe Trial Group. Neonatal Refeeding Syndrome and Clinical Outcome in Extremely Low-Birth-Weight Babies: Secondary Cohort Analysis From the ProVIDe Trial. JPEN J Parenter Enteral Nutr. 2021;45(1):65-78. A total of 600 infants were admitted to the neonatal intensive care unit at our university hospital between April 1, 2009 and July 31, 2011. Among these, 58 infants with a GA between 22 and 29 weeks and a birth weight < 1000 g. Parenteral nutrition was started with a solution containing 5 % – 10 % glucose during the first 24 h of life, then 0.5 g/kg/day of AA after 24 h of life.
On day 8, hypercalcemia ( ≥ 11 mg/dL) was observed in 71 % (12/17) of the SGA group, and 56 % (23/41) of the AGA group. On day 8, hypophosphatemia ( ≤ 2.5 mg/dL) was observed in 53 % (9/17) of the SGA group and 12 % (5/41) of the AGA group. Ichikawa G, Watabe Y, Suzumura H, et al. Hypophosphatemia in small for gestational age extremely low birth weight infants receiving parenteral nutrition in the first week after birth. J Pediatr Endocrinol Metab 2012;25(3-4):317-21. After inclusion of 50 patients, a preplanned safety analysis revealed We did not have blood samples to assess daily development of phosphate electrolyte disturbances and an increased occurrence of or magnesium concentrations, but phosphate concentrations septicemia in the intervention group compared to the correlated positively with the potassium concentrations and control group. Due to the higher rate of infections, the study was inversely with the ionized calcium concentrations. Already by discontinued. Here we describe the electrolyte disturbances and day 3, hypophosphatemia was observed in 10/22 infants in the explore the associations between nutrient supply, electrolyte intervention group compared to 4/23 infants in the control group (P 0.04) metabolism and septicemia.
Moltu SJ, Strømmen K, Blakstad EW, Almaas AN, Westerberg AC, Brække K, Rønnestad A, Nakstad B, Berg JP, Veierød MB, Haaland K, Iversen PO, Drevon CA. Enhanced feeding in very-low-birth-weight infants may cause electrolyte disturbances and septicemia--a randomized, controlled trial. Clin Nutr. 2013 Apr;32(2):207-12 PI - Feeding PI - ReFeeding syndrome syndrome Placental Interrupted Feeding Placental Incompletely Restored syndrome of the preterm infant Feeding syndrome
Bonsante F, Iacobelli S, Latorre G, Rigo J, De Felice C, et al. (2013) Initial Amino Acid Intake Influences Phosphorus and Calcium Homeostasis in Preterm Infants – It Is Time to Change the Composition of the Early Parenteral Nutrition. PLOS ONE 8(8): e72880 PI - Feeding syndrome Placental Interrupted Feeding syndrome of the preterm infant
Bonsante F, Iacobelli S, Latorre G, Rigo J, De Felice C, et al.
(2013) Initial Amino Acid Intake Influences Phosphorus and Calcium Homeostasis in Preterm Infants – It Is Time to Change the Composition of the Early Parenteral Nutrition. PLOS ONE 8(8): e72880 PI - ReFeeding syndrome Placental Incompletely Restored Feeding syndrome
Bonsante F, Iacobelli S, Latorre G, Rigo J, De Felice C, et al.
(2013) Initial Amino Acid Intake Influences Phosphorus and Calcium Homeostasis in Preterm Infants – It Is Time to Change the Composition of the Early Parenteral Nutrition. PLOS ONE 8(8): e72880 DEFINICIÓN OPERACIONAL SD REALIMENTACION-LIKE: Hipofosfatemia Hipercalcemia
Hipokalemia
Hipokalemia Hipomagnesemia
Hipercalcemia Hipofosfemia
Hiperglicemia Déficit de tiamina
Sung SI, Chang YS, Choi JH, Ho Y, Kim J, Ahn SY, et al. Increased risk of refeeding syndrome–like hypophosphatemia with high initial amino acid intake in small-for-gestational-age, extremely-low-birthweight infants. PLoS ONE 2019; 14 (8): e0221042 EPIDEMIOLOGÍA
No hay estudios de incidencia de SR en neonatos
Incidencia de hipofosfatemia: 20-90% ¿Por qué
rango tan amplio?
Bradford CV, Cober MP, Miller JL. Refeeding Syndrome in the Neonatal Intensive Care Unit. J Pediatr Pharmacol Ther 2021;26(8):771–782 Bradford CV, Cober MP, Miller JL. Refeeding Syndrome in the Neonatal Intensive Care Unit. J Pediatr Pharmacol Ther 2021;26(8):771–782 FACTORES DE RIESGO Pequeños para edad gestacional
Restricción de crecimiento intrauterino
RN extremo bajo peso al nacer
Prematuros extremos
Índice de resistencia de arteria umbilical alto
Z score P/T mayor a -2
FISIOPATOLOGÍA Alteraciones electrolíticas Inanición Aumento de insulina Deficiencia de vitaminas Retención de líquidos
Introducción brusca de Hiperglicemia Debilidad muscular Falla alimentación Arritmias orgánica
Ros-Arnal I, Rivero de la Rosa MC, López-Rufasa E, Moráis-López A. Síndrome de realimentación en pediatría: clínica, diagnóstico, prevención y tratamiento. Acta Pediatr Esp. 2017; 75(9-10): e159-e163 Cormack BE, Jiang Y, Harding JE, Crowther CA, Bloomfield FH; ProVIDe Trial Group. Neonatal Refeeding Syndrome and Clinical Outcome in Extremely Low-Birth-Weight Babies: Secondary Cohort Analysis From the ProVIDe Trial. JPEN J Parenter Enteral Nutr. 2021;45(1):65-78. Cormack BE, Jiang Y, Harding JE, Crowther CA, Bloomfield FH; ProVIDe Trial Group. Neonatal Refeeding Syndrome and Clinical Outcome in Extremely Low-Birth-Weight Babies: Secondary Cohort Analysis From the ProVIDe Trial. JPEN J Parenter Enteral Nutr. 2021;45(1):65-78. CLÍNICA
Hipofosfemia severa: 3º-4º día
Desnutrición intrauterina severa: Primer a segundo día
Desde el punto de vista clínico la hipofosfatemia produce dos
complicaciones importantes en este período
Cubillos-Celis MP, Mena-Nannig P. Hipofosfemia en recién nacidos prematuros: un trastorno bimodal. Rev Chil Pediatr. 2018;89(1):10-17 PROBLEMAS RESPIRATORIOS
Dificultad en el retiro del ventilador
Fracaso extubación Mayor duración de requerimientos de oxígeno Mayor displasia broncopulmonar, producida por la hipotonía durante la hipofosfemia.
La hipotonía en hipofosfatemia se produce por la depleción de fosfocreatina y ATP a nivel muscular, lo que se ha documentado con la espectroscopía de RNM y es potenciada por la hipercalcemia concomitante
Cubillos-Celis MP, Mena-Nannig P. Hipofosfemia en recién nacidos prematuros: un trastorno bimodal. Rev Chil Pediatr. 2018;89(1):10-17 INFECCIONES TARDÍAS
Disminución de la actividad Afectación de la serie blanca quimiotáctica, fagocítica y bactericida de los granulocitos.
Cubillos-Celis MP, Mena-Nannig P. Hipofosfemia en recién nacidos prematuros: un trastorno bimodal. Rev Chil Pediatr. 2018;89(1):10-17 OTROS
Hiperglicemia
Severa: • Falla respiratoria • Falla miocárdica por depleción de ATP del miocito • Rabdomiólisis • Anemia por aumento de la rigidez de los eritrocitos que resulta en hemólisis • Convulsiones • Acidosis metabólica
Cubillos-Celis MP, Mena-Nannig P. Hipofosfemia en recién nacidos prematuros: un trastorno bimodal. Rev Chil Pediatr. 2018;89(1):10-17 MANEJO PREVENCIÓN !!
Earlier and adequate provision of
Administrar desde el inicio de la nutrición parenteral -> mayor cantidad si se phosphorous and potassium and adjusted inician AA en altas dosis. calcium and phosphorus ratios in parenteral nutrition support may limit electrolyte Cantidad de fósforo: se puede estimar aproximadamente en base al abnormalities and associated complications aporte de calcio y proteínas
Relación Ca:P inicial debe ser 1:1 en Mmol o 1,3:1 en mg
Programar adecuadamente el aporte parenteral y enteral
Calcio en mg/k/día/2.15 + (aminoácidos en g/K/d-1,3) x 0,8 x 12,3. Controlar fosfemia y calcemia en la primera semana,
Una vez detectada la hipofosfemia puede ser necesario invertir la relación
Ca:P a 0,6-0,8:1 en mg. en la solución parenteral hasta normalizar el fósforo Cubillos-Celis MP, Mena-Nannig P. Hipofosfemia en recién nacidos prematuros: un trastorno bimodal. Rev Chil Pediatr. 2018;89(1):10-17 First Line: Neonatal Stock PN with Phosphate at birth
Second Line: Custom PN
adjustments to amino acids and Calcium:Phosphorus (Ca:P) ratio
