A 17-year-old girl is brought in by her mother for weight loss. BMI is 14 kg/m2. She is amenorrheic for 8 months, has lanugo hair, bradycardia (HR 48/min), hypothermia, and denies body image disturbance. The immediately life-threatening complication that must be managed before nutritional rehabilitation is:

• A Hypoglycemia during re-feeding
• B Refeeding syndrome (hypophosphatemia) ✓
• C Hypokalemia-induced ventricular arrhythmia (from purging)
• D Osteoporosis and vertebral compression fracture

Explanation

Refeeding syndrome is the most dangerous acute complication of nutritional rehabilitation in severe anorexia nervosa. As carbohydrate re-introduction stimulates insulin release, intracellular shift of phosphate occurs causing severe hypophosphatemia (also hypokalemia and hypomagnesemia). This leads to cardiac arrhythmias, respiratory failure, hemolysis, and potentially death. Prevention requires slow, gradual caloric introduction (10-20 kcal/kg/day) with daily electrolyte monitoring and prophylactic phosphate supplementation. Hypokalemia from purging is important but purging was not stated; osteoporosis is a long-term complication; hypoglycemia is managed but less immediately life-threatening than refeeding syndrome.

Reference: Ghai Essential Pediatrics, 10th ed.

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Written and medically reviewed by the StethoPrep medical team.