Clinical characteristics, energy intake patterns, and factors associated with severity of refeeding syndrome in pediatric patients: a single-center retrospective observational study

Refeeding syndrome (RFS) is a critical condition marked by metabolic and electrolyte imbalances during nutritional rehabilitation, particularly in malnourished patients. Data on pediatric RFS remains scarce. This study examined clinical characteristics, energy intake patterns, and factors linked to RFS severity. A retrospective study included patients aged 1 month to 18 years diagnosed with RFS at Srinagarind Hospital, Thailand, between January 2018 and December 2019. Patients were categorized as high-risk or low-risk based on ASPEN consensus criteria. Data on demographics, clinical features, energy intake, and outcomes were analyzed. Multivariable logistic regression examined factors linked to severe RFS. Of 1,677 hospitalized pediatric patients, 135 (8.1%) were diagnosed with RFS, of whom 22.2% were classified as high-risk for RFS. Among patients with RFS, high-risk patients had significantly higher rates of severe malnutrition (BMIZ <-2: 73.3% vs. 15.2%, p < 0.001), prolonged fasting, and ICU admission (30.0% vs. 12.4%, p = 0.046) compared to low-risk patients. Clinical signs of RFS were identified in 16.3% of patients with RFS, with abnormal electrocardiograms (4.4%), heart failure (3.7%), and seizures (2.9%) being the most common. Median energy intake as a percentage of target was slightly higher in high-risk patients (21.0% vs. 14.6%, p = 0.133). High-risk patients more frequently received parenteral or combined nutritional support (24.0% vs. 10.0%, p = 0.019). High-risk RFS status was associated with prolonged fasting and surgical interventions, with a higher prevalence of severe disease (86.7% vs. 62.9%, p = 0.014). Multivariable analysis identified autoimmune diseases, surgical interventions, and hepatobiliary and pancreatic diseases were independently associated with severe RFS. These findings highlight the importance of systematic RFS risk stratification in hospitalized children, particularly for those undergoing surgery or with autoimmune diseases. Proactive identification, close electrolyte monitoring, and timely thiamine supplementation are key to preventing severe complications. Future prospective studies and pediatric-specific risk assessment tools are needed to validate and translate these findings into clinical practice.