Refeeding syndrome in SAM — DTM&H MCQ

Correct answer: C — Refeeding syndrome with hypophosphataemia

The correct answer is C, refeeding syndrome with hypophosphataemia. This infant has classic danger signs of SAM stabilisation gone wrong: hypothermia, hypoglycaemia and bradycardia herald a catabolic to anabolic switch as feeding restarts. Reintroducing carbohydrate triggers an insulin surge that drives phosphate, potassium and magnesium intracellularly, producing profound hypophosphataemia that impairs cardiac, respiratory and neurological function and can precipitate sudden death. This is precisely why WHO SAM protocols mandate cautious, low-osmolarity, low-lactose F-75 feeds during stabilisation, with slow calorie escalation and pre-emptive electrolyte and mineral supplementation before any transition to F-100 or RUTF. Bradycardia and hypothermia in this context are markers of impending cardiovascular collapse from refeeding-induced electrolyte shift, not simple malnutrition itself. Why the other options are wrong: B. Hypernatraemia: SAM children are typically total-body sodium overloaded despite low serum sodium; refeeding causes sodium retention and oedema, not a dangerous acute hypernatraemic crisis explaining bradycardia here. D. Hyperkalaemia: refeeding drives potassium into cells under insulin's action, causing hypokalaemia, not hyperkalaemia; hyperkalaemia is not the mechanism behind this clinical picture. E. Hyperglycaemia: the child is described as hypoglycaemic, reflecting depleted glycogen and gluconeogenic reserve, the opposite metabolic direction to hyperglycaemia. A. Metabolic alkalosis: SAM and refeeding are more typically associated with acidosis or mixed disturbances secondary to diarrhoea and sepsis; alkalosis is not the recognised life-threatening refeeding complication in this setting. Key point: In SAM stabilisation, sudden bradycardia, hypothermia and hypoglycaemia signal refeeding syndrome driven hypophosphataemia, which is why WHO protocols use cautious F-75 feeding with early mineral and electrolyte supplementation.

Reference: World Health Organization, Guideline: Updates on the Management of Severe Acute Malnutrition in Infants and Children (2013), stabilisation phase F-75 feeding and refeeding syndrome prevention; https://www.who.int/publications/i/item/9789241506328