Increased risk of refeeding syndrome-like hypophosphatemia with high initial amino acid intake in small-for-gestational-age, extremely-low-birthweight infants

• Published in: PloS one 2019-08, Vol.14 (8), p.e0221042-e0221042
• Main Authors: Sung, Se In, Chang, Yun Sil, Choi, Jin Hwa, Ho, Yohan, Kim, Jisook, Ahn, So Yoon, Park, Won Soon
• Format: Article
• Language: English
• Subjects: Acids; Age; Amino acids; Amino Acids - metabolism; Analysis; Biology and Life Sciences; Birth weight; Birth Weight - physiology; Demographics; Dietary supplements; Electrolytes; Electrolytes - metabolism; Energy intake; Female; Gestational Age; Health aspects; Humans; Hypophosphatemia; Hypophosphatemia - epidemiology; Hypophosphatemia - metabolism; Hypophosphatemia - pathology; Incidence; Infant; Infant, Extremely Low Birth Weight - metabolism; Infant, Newborn; Infant, Small for Gestational Age - metabolism; Infants; Low birth weight; Magnesium - metabolism; Male; Medical records; Medicine; Medicine and Health Sciences; Mortality; Multivariate analysis; Newborn babies; Nutrition; Nutritional requirements; Parent-child relations; Parenteral Nutrition; Pediatrics; People and Places; Phosphates; Phosphates - metabolism; Physical Sciences; Practice guidelines (Medicine); Refeeding Syndrome - epidemiology; Refeeding Syndrome - metabolism; Refeeding Syndrome - pathology; Respiratory Tract Infections - epidemiology; Respiratory Tract Infections - metabolism; Respiratory Tract Infections - pathology; Risk; Sepsis; Small for gestational age
• ISSN: 1932-6203; 1932-6203
• DOI: 10.1371/journal.pone.0221042

Recent nutrition guidelines for extremely-low-birth-weight infants (ELBWIs) recommend implementation of high initial amino acid (AA) supplementation in parenteral nutrition. We sought to evaluate the influence of AA intake on refeeding syndrome-like electrolyte disturbances including hypophosphatemia in ELBWIs. Medical records of 142 ELBWIs were reviewed. Demographic, nutritional, outcome, and electrolyte data were compared between ELBWIs with initial low (1.5 g/kg/day) and high (3 g/kg/day) AA intake. Multivariate analysis was conducted to determine the odds ratio of hypophosphatemia with high AA intake and small-for-gestational-age (SGA) ELBWIs. The incidence of hypophosphatemia and severe hypophosphatemia increased from 51% and 8% in period I to 59% and 20% in period II, respectively (p = 0.36 and < 0.01). Specifically, SGA ELBWIs showed higher incidence of hypophosphatemia than appropriate-for-gestational age (AGA) ELBWIs in period II, whereas there was no difference in period I. For severe hypophosphatemia, SGA ELBWIs presented a 27% incidence versus a 2% incidence in AGA ELBWIs, even with low initial AA intake. Despite no difference in phosphate intake between infants with and without hypophosphatemia, serum phosphate level reached a nadir at the sixth postnatal day and gradually recovered over the second week in infants with hypophosphatemia. In multivariate analyses, the odds ratios for severe hypophosphatemia were 3.6 and 6.6 with high AA intake and SGA status, respectively, with the highest being 18.0 with combined high AA intake and SGA status. In summary, high initial AA intake significantly increased the risk of refeeding syndrome-like electrolyte dysregulations including severe hypophosphatemia in ELBWIs. In SGA ELBWIs, the risk of electrolyte disturbance was significantly higher, even with low initial AA intake. Therefore, new tailored parenteral nutrition protocols starting with lower energy intake and a gradual increase over the first week may be warranted for application in high-risk SGA ELBWIs.