A 2-year-old child with severe acute malnutrition (SAM, marasmus type) is admitted. On day 2, he develops bradycardia, QTc prolongation, and muscle cramps. The electrolyte most likely responsible and the corrective step is:

• A Hyponatremia — restrict fluids and give hypertonic saline
• B Hypocalcemia — IV calcium gluconate bolus
• C Hyperphosphatemia — restrict phosphate intake
• D Hypokalemia and hypomagnesemia — refeeding syndrome; correct potassium and magnesium before aggressive feeding ✓

Explanation

Refeeding syndrome in SAM occurs when carbohydrate reintroduction shifts potassium, phosphate, and magnesium intracellularly. Hypokalemia and hypomagnesemia cause cardiac arrhythmias (prolonged QT, ventricular arrhythmias) and muscle weakness. WHO SAM protocols mandate potassium supplementation (3–4 mmol/kg/day) and magnesium (0.3–0.6 mmol/kg/day) from the start. Feeding must be started cautiously (F-75 first, then F-100). Hyponatremia is common in SAM but is not corrected with saline (edema risk).

Reference: Ghai Essential Pediatrics, 10th ed.

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Written and medically reviewed by the StethoPrep medical team.