Published in IJCP July 2019
From the Desk of Group Editor in Chief
Bihar Children Deaths: Could Refeeding Syndrome Precipitated by Litchis have Triggered the Deaths?
July 12, 2019 | KK Aggarwal

The recent mortality among children in Bihar due to acute encephalopathy syndrome (AES) has generated speculations abound and raised many eyebrows. The illness has claimed more than 100 lives.

From blaming the government to identifying litchi as the cause of the condition, the hypotheses have been many. However, it is imperative at this juncture to understand that litchi may not be the underlying cause of the symptoms and subsequent deaths, but only a triggering factor.

Most malnourished children below 10 years of age experienced convulsions early in the morning without fever. Despite the fact that all of them had low sugar, mortality still remained high even after infusing sugar. This suggests that apart from sugar, there was some other metabolic factor in play.

Understanding the reaction

In significantly malnourished children, who have not consumed food in the last 24 hours, rapid carbohydrate intake (in the form of litchi in this case, which has 10% sugar) may have led to electrolyte and fluid shifts. This may have in turn precipitated disabling or fatal medical complications. This is also called the refeeding syndrome and is marked by hypophosphatemia (this is the hallmark feature), hypokalemia, congestive heart failure, peripheral edema, rhabdomyolysis, seizures, fever and hemolysis.

We have always been taught to never overfeed a malnourished child as the outcome may be an electrolyte imbalance. Even the World Health Organization (WHO) says that acute or severe malnutrition should be treated slowly over 10 days. Rapid treatment with large intake of litchi may have precipitated fatal electrolyte imbalance.

Rapidly treating hypoglycemia with litchi, without managing phosphate levels, may be harmful. The best food in such a situation could have been sugarcane juice and not litchi. One must remember here that all those who break a long-term fast, do so with sugarcane juice.

The risk of hypophosphatemia during refeeding appears to be greater in patients who are more severely malnourished and at lower percent of ideal body weight. During episodes of starvation, the phosphate stores in the body get depleted. When nutritional replenishment starts and patients are fed carbohydrates, glucose causes release of insulin, which triggers cellular uptake of phosphate (and potassium and magnesium) and a decrease in serum phosphorous levels. Insulin also causes the cells to produce a variety of depleted molecules that require phosphate (adenosine triphosphate and 2,3-diphosphoglycerate), which further depletes the body’s stores of the latter. The subsequent lack of phosphorylated intermediates causes tissue hypoxia, myocardial dysfunction and respiratory failure due to an inability of the diaphragm to contract, hemolysis, rhabdomyolysis and seizures.

Some risk factors for the refeeding syndrome include low baseline levels of phosphate, potassium or magnesium prior to refeeding the patient; and little or no nutritional intake for the previous 5-10 days.

Patients are at the highest risk in the first 1-2 weeks of nutritional replenishment and weight gain. Generally, the risk progressively dissipates over the next few weeks if there has been consistent forced intake and weight gain.

It is also important to note that in cases of acute malnutrition, akin to a prolonged fasting, children should be given only juices upfront. They must not be fed to a full stomach but rather the intake must be increased gradually over a period of time to avoid any negative health outcomes. In the case of children in Bihar perhaps, many of them did not eat for a whole day knowing they will get to eat a generous supply of litchi fruit next morning.

In conclusion, there is a need to raise countrywide awareness, particularly in Bihar, on the fact that children should not be allowed to sleep on an empty stomach. More than anything else, it is the lack of awareness that can magnify any issue, and this was true in the case of these recent deaths as well. A grey area that remains is the disappearance of this disease in the wake of onset of rains, a phenomenon that must be investigated.

A concerted plan of action that takes into account this and other triggers must be formulated. It is time that all stakeholders come together in addressing this health issue, which raises its head every year, causing several deaths.