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Hypophosphatemia is the most common symptom in critically ill children worldwide, but its exact prevalence and relevance to these children remains unclear
.
The incidence of hypophosphatemia in critically ill children has been reported to range from 5% to 76%, depending on the cut-off value
used.
In addition, the consequences of hypophosphatemia remain uncertain, although some studies have reported an association
between hypophosphatemia and worse clinical outcomes in critically ill children.
Hypophosphatemia can be caused by three main mechanisms: decreased intestinal absorption, internal redistribution, or increased
renal loss.
Often, hypophosphatemia is the result of a combination of these factors, such as refeeding syndrome (RFS).
FH is defined as a serum/plasma phosphate concentration of <0.
65 mmol/L and a decrease of >0.
16 mmol/L
within 72 hours of initiation of nutritional support.
This study aimed to investigate the prevalence, risk factors, and outcomes of early RFH in critically ill children and the impact of
early parenteral nutrition on early RFH.
This study is a secondary analysis of a randomized controlled trial of PEPaNIC (N=1440) that showed that delaying parenteral nutrition (PN) supplementation (PN) for 1 week (late PN) in a paediatric intensive care unit (PICU) accelerates recovery and reduces new infections
.
However, patients receiving renal replacement therapy or unusable phosphate concentrations were excluded from
this analysis.
Early RFH is defined as serum/plasma phosphate <0.
65 mmol/L and decreases >0.
16 mmol/L
within 3 days of entry into the PICU.
Associations between baseline features and early RFHs, as well as early RFHs, and association with clinical outcomes were investigated using logistic and linear regression models, with possible confounding factors
not corrected and corrected.
To examine the effect of nutrient intake on phosphate concentration, a structured nested averaging model
with propensity scoring and censoring models was used.
The results showed that a total of 1247 patients were eligible (618 with early PN and 629 with late PN).
In total, 40 patients (3%) developed early RFH, with the early PN group (n = 31, within-group incidence 5%) being significantly higher than the late PN group (n = 9, within-group incidence 1%, p < 0.
001).
。 Older adults (risk factor OR 1.
14 (95% CI 1.
08; 1.
21), p < 0.
001) and a higher risk of pediatric mortality (PIM3) score had a higher risk of early RFH (OR 1.
36 (95% CI 1.
15; 1.
59, p < 0.
001), compared with a lower risk of early RFH in the advanced PN group (OR 0.
24 (95% CI 0.
10; 0.
49), p < 0.
001).
。 Early RFH was significantly associated with a 56% increase in length of stay in PICU (p = 0.
003) and a 42% longer length of hospital stay (p = 0.
007), but not associated with new infection (OR 2.
01 (95% CI 0.
90; 4.
30), p = 0.
08) or length of mechanical ventilation support (OR 1.
05 (95% CI −3.
92; 6.
03), p = 0.
68)
。
This study confirms that early RFH occurs in
3% of critically ill children.
Patients randomized to advanced PN have a lower chance of developing early RFH, possibly due to
gradual accumulation of nutrients.
Because early RFH may affect recovery, it is important to closely monitor phosphate concentrations in patients, especially those at risk for early RFH
.
Original source:
K.
Veldscholte.
et al.
Early hypophosphatemia in critically ill children and the effect of parenteral nutrition: A secondary analysis of the PEPaNIC RCT.
Clinical Nutrition.
2022.